Technique

UPP measurement is contraindicated in the presence of a urinary tract infection. Some centers give a single dose of prophylactic antibiotics prior to the test. UPP measurement may be made 1. At rest (resting UPP) with the patient and the urethra at rest 2. During stress (stress UPP) by applying a defined provocation (e.g., cough, valsalva) 3. While voiding this technique is fraught with technical difficulties, is rarely used in clinical practice, and will not be discussed any further The test...

Interpretation

Interpretation of the MCUG is discussed in chapter 11 on the investigation of the pediatric patient with hydronephrosis. The discussion here will be confined to the patient with bladder injury. Pelvic fractures are complicated by bladder rupture in 5-10 of cases and static cystography (or CT cystography) diagnoses the rupture in virtually all cases, providing adequate distension of the bladder with contrast has occurred. A blood clot or omental flap may temporarily plug a small tear and cause...

Contents

Preface (1) Urine (b) Flow (d) Glomerular Filtration Rate 25 (e) Creatinine (f) 24-Hour Urine for Urinary Protein Excretion (g) 24-Hour Urine Analysis for Stone Formers (h) Urinary Electrolytes (i) Renal Tubular (j) Adrenal-Specific Urinary Tests 40 (k) Urinary Markers for TCC Detection 42 Cancer (2) Blood (a) Prostate-Specific Antigen (PSA) 47 (c) Testicular Tumor Markers 55 (d) Bone Disease Related to Urology 61 (e) Sex Hormone (f) Serum Markers of Adrenal Function 64 (a) Plain Abdominal...

Info

More PSA per gram is produced by BPH (0.2 ng mL of serum PSA per 1 g of BPH) than by normal prostatic tissue, making BPH the most common reason for mild elevations in serum PSA up to 10 ng mL. The sensitivity of serum PSA ranges from 57 to 79 and specificity from 59 to 68 for CAP and in isolation, is insufficient to accurately distinguish between BPH and CAP. Therefore, within the range PSA 4-10 ng mL, there is considerable overlap between men with BPH and early CAP, with the majority of...

Virtual endoscopy

By using a surface-rendering technique, CT images can be utilized to enable imaging of hollow organs such as the bladder and ureter. Virtual endoscopy Has the main advantage of being non-invasive Permits good visualization of the tumor morphology as well as reasonable demonstration of the bladder ureter wall Is unable to detect flat mucosal lesions, such as carcinoma in situ Imparts no data with regard to tumor grade and stage The overall sensitivity and specificity of virtual ureteroscopy are...

B

MR spectroscopy MR spectral trace from (A) normal peripheral zone prostate tissue and (B) Gleason 7 peripheral zone prostate cancer (With permission from Elsevier Coakley, J Urology, Vol 170, FIGURE 3.7. MR spectroscopy MR spectral trace from (A) normal peripheral zone prostate tissue and (B) Gleason 7 peripheral zone prostate cancer (With permission from Elsevier Coakley, J Urology, Vol 170, There is emerging evidence that, in patients with an abnormal PSA and negative prostate...

Indications

Direct prostate biopsies for the detection of CAP If PSA > 4 ng mL (some authors suggest a lower cut-off of 2.5 ng mL) Presence of high-grade prostatic intraepithelial neoplasia (PIN) in previous biopsies between 27 and 79 will have evidence of CAP in repeat biopsies Rising PSA or palpable abnormality following definitive treatment Local staging in established prostate cancer Treatment planning (for thermal coil placement or interstitial radioactive seed placement on brachytherapy) To...

Overview

Recent years have seen an increase in the usage of magnetic resonance imaging (MRI) to image the urinary tract. Faster scanners can now provide high-resolution multiplanar images for accurate diagnosis. While it is beyond the scope of this book to elucidate the physics of MRI, an understanding of basic principles is desirable. The fundamental basis of MR scanning is the conversion of radiofrequency energy into gray scale, to allow production of an image. Nuclei, with unpaired electrons, behave...

Technique and findings

The ideal time for surgery is between 12 and 18 months of age (although laparoscopy is safe in infants as young as 3 months) Performed as a day-case procedure if uncomplicated Informed consent is obtained from the patient's guardian Performed under a general anesthetic, with the patient supine Following Veress needle puncture or open access (e.g., Hasson technique), the peritoneal cavity is insufflated to a pressure of around 10 mmHg A single 2- or 5- mm port is placed through the umbilicus...

Prostate biopsy

Prostate biopsy remains a controversial issue with no standardized consensus with regard to technique, number of biopsy cores and region of prostate to be biopsied. The larger the gland, the lesser the likelihood of CAP detection and the greater the false-negative rate. The rate of CAP detection increases from 23 to 31 in glands > 50 cc to 38-50 in glands measuring < 30 cc. Generally, more biopsy cores must be taken in prostates which are larger on TRUS volume estimation. In patients...

Ph

5.8-6.8 Low urine pH (< 5.8) promotes uric acid crystallization, but reduces citrate excretion Persistently elevated pH (secondary to ammonium and bicarbonate produced by urea-splitting organisms) is associated with struvite stone formation < 1.010 Sufficient urine dilution is achieved with a urine production of > 2L day > 2L Maintaining urine output of > 2L 24h is the single most important therapeutic consideration Corresponds to fluid intake of 2.5-3L day < 5 mmol Over half the...

Drawbacks

Hematuria, rectal bleeding, or hematospermia (> 50 ) 3. Inaccuracies in cancer staging (sensitivity for detection of extra-capsular penetration is around 60 ) 4. Imaging prone to artifacts (e.g., secondary to air, calcification, rapid movement) 5. Vasovagal episodes due to vagal nerve stimulation (< 5 )

H Sphincter Electromyography Emg Overview

Sphincter EMG is used in urodynamics to evaluate the electrical activity of the striated sphincter muscle and the pelvic floor striated muscles that aid urinary continence. The functional unit in EMG is the motor unit, which comprises a single motor neurone and the muscle fiber it innervates. At rest, the contracted external urethral sphincteric (EUS) gives rise to low amplitude electrical activity on the EMG. EMG alone gives useful information about EUS function, but it is most valuable when...

Technique and radiation

The optimal time for DMSA scanning remains an unresolved issue. Many units perform the study in the acute phase (i.e., during or soon after a UTI) in order to determine the extent of parenchymal involvement. Critics of such practice point out that an acute abnormality does not necessarily represent a permanent scar and a repeat scan is often required after 3-6 months to determine longstanding injury. Deferring the DMSA scan for such a period of time may avoid the initial examination. 99mTc-DMSA...

Uti

24-hour urine for protein excretion Referral to nephrologist Renal biopsy Rule out urological cause Treat underlying condition Microscopy may also reveal squamous, transitional, and renal tubular cells. Squamous cells originate from the vagina, urethra, or trigone and typically appear large with irregular cytoplasm and a small, central nucleus Transitional cells are smaller with prominent cytoplasm staining, and have a large nucleus. The features of malignant transitional cells are discussed...

Blood

Detection of blood is due to peroxidase-like activity of hemoglobin, which catalyzes the oxidation of a chromogen indicator, causing a color change in direct proportion to the amount of blood in urine Hematuria, hemoglobinuria, and myoglobinuria will all result in positive dipstick for blood Dipstick detection of hematuria (defined at > 3 RBC high-power field) has a sensitivity of over 90 There is also a higher false-positive rate Common causes of false-positive results include (i) Urine...

Urine Tests

Urinalysis is a requisite examination in the assessment of all urological patients and comprises A. Physical examination of urine C. Microscopic analysis of urine Appropriate specimen collection and transport is vital for accurate and clinically valid results. The typically acidic and concentrated early morning urine (EMU) samples are more likely to detect a urinary tract infection (UTI), since red blood cells (RBC), white blood cells (WBC), and casts are best preserved in such a medium. In...

A Chronic Bladder Pain Interstitial Cystitis IC

Patients describe pain, frequency, and nocturia Diagnosis based on symptoms, examination, urinary investigation and cystoscopy List of automatic exclusions include Lower urinary tract or gynaecological tumors Cystitis (bacterial, tuberculous, radiation, drug-induced) or vaginitis Bladder or lower ureteric stones Frequency of < 5 times in 12 hours Bladder capacity > 400 mL Detrusor overactivity on UDS

Modifications of PSA testing

Larger prostate glands will produce more PSA. Therefore, in an attempt to resolve the considerable overlap in serum PSA between patients with BPH and early CAP, the notion of PSA density (PSAD) was introduced PSAD serum PSA divided by prostatic volume in mL (as estimated by TRUS) Traditional recommended cut-off of 0.15 PSAD was not recommended in patients with a low (< 4.0 ng mL) or high (> 20 ng mL) PSA Presumed greatest utility in the 4-20 ng mL PSA range, in terms of determining the need...

Blood Tests

Is a 34-kilodalton (kDa) glycoprotein produced by the prostatic secretory epithelial cells which line the acini and the ducts of the prostate gland Is expressed in both benign and malignant prostatic conditions Is found in high concentrations in semen and is thought to cause liquefaction of the seminal coagulum Has a half-life of 3.2 days Is elevated in CAP and a variety of benign prostatic diseases (benign prostatic hyperplasia BPH and prostatic inflammation) Is organ-specific, but serum PSA...

Boo

Urethral stricture Incomplete emptying of urethra Lower urinary tract infections Chronic retention of urine Large bladder diverticulum Severe VUR (in the latter two due to accumulation of false residual urine in the bladder) Urethritis (urethral syndrome) Lower tract infections Atrophic vaginitis Chronic pelvic pain syndrome (prostatitis) Chronic pelvic pain syndrome Acute retention of urine Interstitial cystitis (urethritis, prostatitis) Interstitial cystitis Urethral stricture Impacted...

Glucose

Detection occurring due to a double oxidative reaction of the glucose with glucose oxidase on the dipstick is specific for glucose and does not occur with any other sugars. Patients with a positive glucose dipstick should be investigated for diabetes mellitus. Glucosuria should not be present in the normal healthy adult A positive dipstick suggests that the renal tubular reabsorption threshold has been exceeded. This corresponds to a serum glucose level of about 18 mg L Nevertheless, the degree...

H Standard Semen Analysis Overview

Infertility, defined by the inability of a couple to conceive after 1 year of unprotected intercourse, is relatively common. Male factor problems responsible in 50 of cases Semen analysis is the cornerstone of evaluation of the male partner Semen analysis is highly indicative of the functional status of the testis by assessing the quantity, quality, and capabilities of semen in that particular specimen. Most men comply readily with semen analysis, but a small proportion of patients find...

A

UPP of female (top) and male (below) urethra distance along urethra FIGURE 5.4. UPP of female (top) and male (below) urethra There tends to be a normal response to stress and adopting an upright position MUCP of > 70 cmH2O can be commonly found 4. Detrusor-sphincter dyssynergia Instead of a drop in urethral pressures during voiding, there is an abnormal simultaneous increase 5. Post-prostatectomy stress incontinence Associated features include an absence of...

Additional investigations

Radionucleotide study (renography) to assess relative renal function Presents with LUTS frequency, urgency, hesitancy and dysuria Dysuria may radiate to the labia or tip of the penis Physical examination findings usually non-specific 1. Urine dipstick hematuria and leukocytosis usually present 2. Cystoscopy is both diagnostic and therapeutic (cystolitholopaxy) Additional investigation (these will detect the bladder calculi but ultimately cystoscopy will be required for treatment)

Additional recommended investigation

TRUS (to exclude structural abnormalities) Cystoscopy (to exclude urethral or intravesical lesions) Table 8.1. LUTS and conditions LUTS_ ureteric stent) bladder capacity (e.g., interstitial Detrusor overactivity Nocturnal polyuria (> 30 of daily urine production occurs at nighttime hours) Chronic retention of urine Large bladder diverticulum Severe VUR Carcinoma in situ Small bladder capacity Habitual BOO Genuine stress incontinence External urethral sphincter weakness (e.g.,...

Advantages

Safe no radiation involved Cheap therefore readily available No requirement for intravenous contrast Excellent anatomical detail Occasional functional physiological information Doppler studies excellent for vascular flow studies Useful adjunct to interventional procedures (e.g., nephros-tomy, abscess drainage)

B Epididymitis

Can affect males of any age Gradual onset scrotal pain, swelling, and erythema Some patients may complain of concurrent LUTS and fever A tender, swollen epididymis is the most common finding 1. Urine dipstick may suggest infection (leukocytes, nitrites) 3. Urethral swab to exclude chlamydia in the sexually active male 4. USS may reveal a swollen epididymis color Doppler may demonstrate increased blood flow useful to confirm the absence of intratesticular malignancy. (Note an anatomical or...

B Urinary Tract Infection Uti Overview

The urinary tract is a common source of infection in the pediatric population 4 of girls and 1 of boys will have a UTI before puberty 50 of girls with one UTI will have a further infection E. coli is responsible for around 85 of UTI in children Mechanisms of pathogen entry include Retrograde ascent of perineal bacteria (most common) Following instrumentation of the urinary tract Involvement of the urinary tract as part of systemic infection The significance of pediatric UTI is that between 30...

C Posterior Urethral Valves Puv Overview

Comprise membranous mucosal folds which obstruct urine flow during micturition Most common obstructive lesion of the urethra in children Incidence of 1 in 4,000-8,000 > 80 are detected pre-natally fetal USS detects a persistently distended bladder and bilateral upper tract obstruction Found at the level of the distal prostatic urethra Typically, the membrane arises from the veru montanum and extends anteriorly through the area of the external urethral sphincter to attach to the anterior...

C Obtaining A Glomerular Filtration Rate Gfr

GFR estimation is invaluable in the management of patients with or at risk of renal impairment GFR is defined as the volume of blood from which a solute is cleared by glomerular filtration through the Bowman's capsule per unit time (mL min) GFR is regarded as a measure of global function Various techniques of GFR calculation have been described The more accurate techniques (e.g., inulin clearance) are impractical for routine medical use, but the more workable methods (e.g., serum creatinine,...

C Subfertility

Inability to conceive after 1 year of unprotected intercourse Male factors solely responsible for 20 of cases and play a contributory role in another 30 Both partners should be investigated simultaneously, since female factors such as age, previous pregnancies, and medical Nocturnal penile tumescence and rigidity Serum FSH and LH if testosterone low Thyroid function tests Tumescence and rigidity can be measured at the base and tip of penis using the Rigiscan Can help differentiate between...

C Ultrasound Scanning Uss Overview

USS relies on a dual-mode transducer, which first sends high-frequency sound waves into the patient and then receives the reflected waves to generate an image Images may be displayed as a two-dimensional gray-scale image or as a color Doppler Frequencies used in medical sonography range from 2 to 10 MHz The higher the frequency, the better the resolution, but the poorer the depth of penetration. Small part probes for scanning testes and the penis operate at a frequency of between 7 MHz and 9...

D Bone Scan Overview

Bone scintigraphy is the most commonly performed nuclear medicine study Diagnostic accuracy of about 95 for skeletal metastatic disease Invaluable tool in the staging of urological cancers Primary urological malignancies (prostate and kidney) are a common cause of skeletal secondaries The information provided by the bone scan reflects metabolic activity within the bones. The most commonly used disphospho-nate tracer, 99m Tc-methylenediphosphonate (medronate), is adsorbed onto the surface of...

D Computed Tomography Ct Introduction

The advances in computed tomography (CT) scanning have revolutionized uroradiological imaging, such that in many practices it often is the first and only investigation performed for a variety of urological complaints. Collimation allows a rotating thin beam of X-rays to pass through the patient's body, which is attenuated by absorption and scattered as it is passed through the patient. A computer produces a composite image using the transmitted beams. The present third- and fourth-generation CT...

D Laparoscopy For Undescended Testis Overview

Cryptorchidism or undescended testis (UDT) Has an incidence of 3-5 (at birth) and 0.8 (age of 1 year) May affect one or both (20 bilateral) testes Requires mandatory evaluation due to concerns about malignant change and decreased fertility in the cryptorchid testis Laparoscopy is a safe and well-established therapeutic technique in modern day adult and pediatric urology. However, it is also a diagnostic tool and its most extensive application has been in the management of the impalpable...

D Prostate

Increased male life expectancy and PSA screening program is resulting in a rapid increase in incidence May or may not present with symptoms (LUTS, bone pain from metastatic disease) TNM classification of prostate cancer clinically not palpable or not visible on imaging

D Undescended Testis Udt Overview

Incidence at birth is between 3.4 and 5.8 at birth Incidence drops to 0.8 by the age of 1 year Well-recognized manifestation of over 50 congenital syndromes Approximately 25 of cases are bilateral UDT is broadly classified into The diagnosis is usually made on clinical examination at birth, but all patients must be followed up with serial examination up to the age of 2 years. Spontaneous descent will occur in over 70 within the first year of life (mainly within the first 6 months). A...

Dilute urine

Urine in which albumin is not the primary protein The detection of proteinuria on a dipstick is a measure of protein concentration and not protein excretion therefore, measurement of 24-hour urinary protein excretion and protein electrophoresis is mandatory to rule out underlying renal disease. Proteinuria can be classified by timing into 1. Transient common occurs in children also in patients with sepsis, cardiac failure and following exercise spontaneous resolution 2. Intermittent occurs in...

E PENIS

Squamous cell carcinoma is the most common type Several pre-malignant conditions including balanitis xerotica obliterans, leukoplakia, penile cutaneous horn, condyloma acuminate, penile carcinoma in situ (Bowen's disease, eryth-roplasia of Queyrat, and bowenoid papulosis) TNM classification of penile tumors Tx primary tumor can not be assessed Ta non-invasive verrrucous carcinoma T1 invasion of subepithelial connective tissue T2 invasion of corpus spongiosum or cavernosum T3 invasion of...

E Positron Emission Tomography Pet Scan Overview

In nuclear medicine studies, the planar imaging commonly utilized provides a tracer distribution image in two dimensions. The basic aim of PET scanning is to create an image representing three-dimensional (3D) distribution of tracer, by combining the use of positron-emitting radionuclides and emission CT. Initially, a research tool for a number of years, PET scanning is now emerging as a useful clinical tool in the management of patients with a variety of pathological conditions, although its...

E Urinary Incontinence

Day- or nighttime urinary incontinence is common in children By the age of 7 years, 6 of girls and 3.8 of boys continue to have problems with daytime incontinence Can be classified as either nocturnal or diurnal functional or organic An organic etiology is uncommon but must be excluded Primary nocturnal enuresis is rarely due to an organic factor Continuous leakage almost always has an organic etiology Children who were once dry but subsequently developed incontinence virtually never...

Ed

Formal investigations usually not required An accurate record must be made of the number, size, location, and consistency of penile plaques Indications for formal assessment include Presence of complex deformities If surgery is being considered Monitoring of medical therapy Persistence of diagnostic doubt As part of a research protocol Advanced investigations for Peyronie's disease are summarized in Table 12.3.

Edta

Should emit only gamma rays (100-200 keV energy) 5. Half-life long enough to complete investigation 6. Half-life short enough to minimize patient radiation risk Table 4.2 describes the characteristics of the commonly used radiopharmaceutical. Therefore, nuclear medicine techniques in renography can evaluate Renal glomerular filtration The agent of choice will primarily depend on the precise function being evaluated. Positron emission tomography (PET) is an...

F Magnetic Resonance Spectroscopy Overview

MRI has a developing role in the management of CAP Magnetic resonance spectroscopic imaging (MRSI) combines magnetic resonance and spectroscopy to generate three-dimensional anatomical information with superimposed metabolic data, thus increasing its clinical utility MRSI has been tested in renal cancers but most studies have focused on its role in CAP Alignment of the hydrogen nuclei (proton) within a strong external magnetic field is the basis of MR scanning. Fundamental to MRSI is the...

F TESTIS

Usually present as painless scrotal lump Primary tumors common in young men Lymphoma common in older men Intratubular germ cell neoplasia Seminoma Leydig cell tumor Sertoli cell tumor Granulosa Mixed TNM classification of testicular tumors TNM classification of testicular tumors tumor limited to testis and epididymis without vas-

F Urethral Swabs Overview

Urethral swabs are taken primarily for the diagnosis of sexually transmitted infections (STI) in men. Typical symptoms include any of the following Non-specific symptoms suggestive of pelvic inflammatory disease Microbiological analysis using urethral swabs is easy, safe, and is reasonably sensitive in males. In females however examining a gram-stained smear from an isolated urethral swab sample is often insufficient to make the diagnosis, and a full pelvic bacteriological screen including a...

F

Ii . 12 , 30 , 70 , 90 , and 120 lenses Maximum deflection in one plane is 180-120 Upper tract manipulation (e.g., ureteric catheterization or stent insertion) Lithoclast Bladder washout Electrocautery or laser ablation of small tumors Retrograde pyelography Insertion removal of ureteric stents Better visualization due to superior optics Does not require sedation or anesthesia Can be performed supine Flexibility better visualization of bladder neck Usually requires sedation, spinal, or general...

Fvc

Urodynamics filling and voiding cystometry Confirm reduced bladder compliance Exclude detrusor overactivity Hunner's ulcer confirms diagnosis of IC Glomerulations (petechial hemorrhages) is very suggestive of IC Biopsies may support diagnosis of IC (and help exclude CIS) (b) Prostate Pain Syndrome Prostatitis Four types of prostatitis recognized Chronic pelvic pain syndrome A inflammatory WBC in semen EPS VB3 urine B non-inflammatory no WBC in semen EPS VB3 urine Asymptomatic inflammatory...

Hematuria

A common urological condition If heavy, hospitalization may be required In most patients > 40 years of age, further investigations are mandatory A urinary tract abnormality is found in > 20 of the cases (see Table 10.1) Urological cancers may present as hematuria For microscopic & dipstix hematuria 2. Serum electrolytes and creatinine 5. Consider referral to nephrologist (may require renal biopsy ) 6. Cytological examination of urine 3. Serum electrolytes and creatinine TABLE 10.1....

Bladder Outlet Obstruction

Benign prostatic obstruction (symptomatic, retention of urine) Typically, symptoms of flow disturbance (e.g., hesitancy, poor, prolonged, or intermittent flow) dominate over irritative (frequency, urgency, and urge incontinence) symptoms Acute or acute on chronic retention (painful) Chronic retention is usually painless residual urine usually > 1 liter (Tip history of incontinence including bed wetting in the presence of a palpable bladder should alert the clinician to the possibility of...

Doppler Studies Overview

Doppler technology is a useful adjunct to USS Technological advances have increased its utility in the realtime investigation The Doppler effect is a physical phenomenon which demonstrates a change in the frequency of a signal due to the relative movement of the signal source compared to the observer The Doppler signal is usually in the audible range Application of an ultrasound beam will allow the measurement of flow direction and velocity of any structure which moves (e.g., flow of RBC in a...

Upper Urinary Tract Obstruction

Symptoms may be similar to renal or ureteral calculi Symptoms based on the acuteness of obstruction Urinary tract infection or mild abdominal loin discomfort often present High-grade fevers or sepsis may ensue, due to the chronicity of the obstruction Typically have loin pain after diuresis (drinking caffeinated beverages or alcohol) Nausea and vomiting are common

Lower Urinary Tract Infections

Minimal set of investigations (if solitary UTI in a female) MSSU Recommended investigation (if recurrent UTIs UTI in male patients or upper tract involvement pyelonephritis) Flow rate and post void residual urine volume estimation (especially in men) KUB to exclude renal tract calculi USS of upper urinary tract Flexible cystoscopy (in intractable cases) may also be therapeutic in case of recurrent urethritis urethral syndrome in women Expressed prostatic secretions for microscopy and culture...

Indirect micturating cystography

Practice of this technique, which negates the use of a catheter, has many advantages in the pediatric population Will primarily demonstrate reflux Enables estimation of split renal function Demonstrates cortical scarring Allows valuable assessment of bladder function The well-hydrated patient is injected with an MAG3 tracer. If renography is required, data collection can commence immediately. The patient is then asked to void 30-60 minutes following tracer injection as data acquisition...

Infection

Trauma to vas and cord structures Accurate in detection of impalpable testis Dual-purpose, minimally invasive procedure (diagnosis and therapeutic) Avoids laparotomy and therefore decreases morbidity Any other imaging technique to locate the testis would require a general anesthetic as well TABLE 6.3. Possible outcomes during pediatric laparoscopy for UDT Blind ending vas and spermatic vessels above the internal inguinal ring (44 ) Intra-abdominal testis located either adjacent to the internal...

Introduction

Nuclear medicine techniques are integral to modern urological practice and can be used to investigate almost any organ in the body. Urological usage is primarily confined to Assessment of renal imaging, function, and drainage Management of metastatic prostate cancer Isotopes of an element share the same atomic number (and therefore the same biochemical characteristics) but differ in their mass number (as well as their energy states). An example is the isotopes of iodine (123I, 131I, 125I). When...

Investigations

Doppler USS can confirm diagnosis and grading. All grade III varicoceles should undergo USS of the retroperitoneum to exclude obstruction of the testicular vein (e.g., from a renal tumor, retroperitoneal nodes). 2. Venography in some centers, venography is preferred for demonstration of varicocele anatomy. This has been the traditional gold standard investigation, but due to its invasive nature (requires access through either the common femoral or internal jugular vein), it has been superseded...

Investigations if tumor suspected

Urinary adrenal markers (see Chapter 1e Urinary Adrenal Markers) Serum adrenal markers (see Chapter 2f Serum Markers of Adrenal Function) CT scan (pre- and post-contrast) or MR scan CT can differentiate between benign and malignant tumors based on Washout of contrast from the tumor Pre-contrast CT is performed Administration of IV contrast Delayed scan performed after 2 minutes If > 50 contrast washout it is less likely to be malignant Other features size (> 3 cm, presence of...

Investigations if upper tract tumor suspected

Retrograde ureterogram (not as reliable as endoscopy) Upper tract endoscopy (uretero-pyeloscopy) Larger exophytic tumors may be seen with above imaging studies Tumors located at the bladder base may be difficult to differentiate from an intra-vesical prostate growth (benign or malignant) CT and or MR can help stage urothelial tumors (but post-resection edema may be confused with invasive disease on CT MR scanning) The imaging modalities are diagnostic aids only and endo-scopic confirmation of...

IVU in children

Has been largely replaced by USS, CT scanning, and nuclear medicine studies Still useful in children with complicated stone disease, abnormal variant upper tract anatomy, and hematuria Certain modifications are required Limit amount of contrast (1 mL kg body weight) Limit number of films to three

J Cystogram Overview

Cystography provides a more thorough examination of the bladder using direct contrast instillation Contrast media may be introduced in a retrograde fashion (via the urethra) or percutaneously (suprapubic bladder puncture) Cystography can be divided into three categories 1. Static (simple) this forms the bulk of the discussion in this chapter 2. Dynamic as part of urodynamic evaluation of the lower urinary tract (discussed in Chapter 5f Videouro-dynamics) 3. Micturating cystourethrography...

LDI isoenzyme of LDH

Recent evidence has suggested that LD1 may be a useful tumor marker in the management of testicular germ cell tumors based on certain observations. In patients with seminoma, LD-1 is elevated more often AFP and phCG In metastatic disease, LD1 appears to be a superior prognostic marker than serum LDH LD1 is a better predictor of relapse in patients with non-seminomatous germ cell tumors compared to the other tumor markers LD1 reflects a typical chromosomal abnormality noted in patients with germ...

Limitations

Cystometry has a number of pitfalls The artificial surroundings of the urodynamic laboratory can inhibit voiding in up to 30 of women Time-consuming, invasive, and prone to artifacts Lack of standardization of technical aspects, such as patient position, type of transducer catheter, and filling rate may cause variable results A wide range of normal values therefore not all abnormal results are significant Intra-patient variability on repeat examination Normal cystometric findings do not...

M

Magnetic resonance imaging (MRI), 99-106 advantages and in combination with fistulography, 131 magnetic resonance spectroscopy, 107, 108 magnetic resonance spectroscopy, 109 contraindications to, 101-102 contrast media in, 103, 104 indications for, 100-101, 103, 247, 265 interpretation of, 104-107 penile, 247, 262 Magnetic resonance imaging (MRI) (cont.) during pregnancy, 101-102, 104 technique, 101-104 Magnetic resonance spectroscopy advantages and disadvantages of, 109-110 in combination...

Metformin and contrastrelated nephrotoxicity

Metformin accumulates in the kidneys if renal excretion is impaired following contrast injection and can therefore cause lactic acidosis, further aggravating the renal insult. Preexisting renal insuffiency, dehydration, and continued use of metformin (in the presence of renal impairment) are the main risk factors. The European Society of Urogenital Radiology guidelines have been summarized below (Table 3.2). T serum creatinine (> 25 or 44mmol L) Deterioration peaks within 3-4 days, but...

Minimal set of investigations for pediatric incontinence

USS allows rapid assessment of entire urinary tract Additional investigations These are rarely required for isolated symptoms of incontinence because the baseline investigations are adequate to reassure both the physician and patient parents in most cases. These tests are only suitable for older children, who are able to comply with simple instructions. Indications for advanced testing include Suspected neurogenic bladder Continued troublesome symptoms without a satisfactory diagnosis Suspected...

Minimal set of investigations for ED

Abdomen, external genitalia, and rectal Global endocrine function body habitus, hair distribution Femoral and lower limb arterial pulses Perineal and lower neurology Assessment using standardised questionnaires Standardized questionnaire (e.g., International index of erectile function) will allow objective analysis of disease severity Appropriate laboratory tests Urine dipstick to detect glucosuria or hematuria MSSU to exclude infection Fasting blood glucose diabetes mellitus Fasting lipid...

Minimal set of investigations for UPJO or VUR

Renal function assessment serum creatinine estimation or more sophisticated techniques of renal function estimation (e.g., creatinine clearance) 4. USS will demonstrate kidney size, thickness of the parenchyma, cortical echo-pattern, AP diameter of renal pelvis, calyceal ectasia, width of ureter, bladder wall thickness, and residual urine 5. MCUG will confirm presence of VUR and allow grading. Also useful for evaluation of urethral valves 6. Static (DMSA) renal scintigraphy ideal method for...

Minimal set of investigations for UTI

MSU specimen collection may involve a clean catch (in boys), collection bag (most common but not ideal), catheterization (invasive), and suprapubic aspiration. Samples must undergo standard microscopy and culture 3. USS the initial radiological investigation of choice for examination of entire renal tract 4. MCUG indicated routinely in all patients under the age of 2 years, but also in > 2-year-olds if history of febrile illness, recurrent UTI, or renal scarring 5. Static (DMSA) renal...

Nephrostogram

Can be performed immediately or deferred till the system has been adequately drained or in the presence of infection Between 50 and 100 mL of Urograffin 150 is used (but any HOCM or LOCM 150-200-strength media can be employed) Any residual contrast should be removed from an obstructed system to minimize risk of a chemical pyelitis Simple nephrostogram can be performed as an outpatient procedure, but overnight hospital stay is required if a percutaneous procedure has been performed The...

Nitrites

Common urinary gram-negative bacteria can convert nitrates to nitrites A positive nitrite dipstick has a high specificity for detecting bacteruria (> 90 ) but its sensitivity is variable (40-85 ). Accuracy is also diminished in subclinical bacteruria (< 105 organism mL) Contamination can result in a false-positive result In the hospital setting, urine dipstick for leucocyte esterase and nitrites is not an adequate replacement for urine microscopy and culture in the detection of urinary...

Obstructive

Congenital congenital absence of vas deferens (associated with cystic fibrosis) Acquired vasectomy or infection (e.g., epididymitis) Motility probably more important than sperm count Causes include prolonged abstinence, excessive heat (e.g., vari-cocoeles, hot baths), excessive alcohol, smoking, recreational drugs, toxin exposure (e.g., solvents, pesticides, lead, mercury, gold), urogenital infection, anti-sperm antibodies (e.g., after vasectomy or testicular trauma), partial ductal...

Osteomalacia

CRF results in inadequate conversion of 25-hydroxy-Vit D to the more potent 1,25-dihydroxy-Vit D, and therefore results in insufficient mineralization of the osteoid framework Results in soft bones, bone pain, and pathological fractures Serum bone markers may be normal and the diagnostic gold standard remains the bone biopsy In conclusion, Table 2.7 highlights certain trends in serum values of the common bone markers in pathological conditions.

Overall advantages and disadvantages

Single imaging technique for visualization of the entire renal tract with excellent anatomical detail Simultaneously detects non-urological pathology (e.g., liver) Identifies virtually all renal and ureteric calculi Increased sensitivity in detection of renal masses Allows accurate staging of detected malignancies 3D reconstruction enables delineation of anatomy and aids surgical planning CT angiography (non-invasive) as accurate as conventional angiography (invasive) Often requires...

Preface

As this book was going to press, the Editor-in-Chief of the British Journal of Urology International introduced an interesting and timely phrase finger tip urology. He has rightly pointed out that medical knowledge base is expanding so rapidly that no urologist can keep pace. The implication is that there is a desperate need for an easy reference source in many areas of urology. We think that this book is spot on Urological diagnosis is rarely possible without tests. And there are several tests...

Protein

Proteinuria in adults is defined as the excretion of > 150 mg of protein per day (normal protein excretion rate is 80-150 mg) Dipstick analysis will detect concentrations as low as 10 mg dL The protein concentration of urine alters the urine pH and this results in a change in the color of the pH-sensitive dye on the dipstick. Albumin, the primary urinary protein, causes the dipstick to turn green the darker the green, the greater the urinary protein concentration. Causes of false negatives...

Renal puncture

Pelvicalyceal system is punctured using a long exploring 22 G needle (e.g., Kellet needle) It is important to avoid direct puncture of the renal pelvis due to risks of laceration, bleeding (without the tamponade effect of the parenchyma) and extravasation of urine Line of entry should be through the parenchyma, then into a calyx and then into the renal pelvis Urine aspiration will confirm correct placement Injection of contrast can provide additional verification Access is secured by the...

Specific gravity SG

Measure of total solute concentration Usually varies between 1.001 and 1.040 SG of > 1.020 is concentrated SG of < 1.008 is considered dilute The state of hydration and renal insufficiency are the two main determinants of urine SG. SG decreases with age as the renal concentrating ability diminishes Over-hydration, diuretic therapy, diabetes insipidus, and renal failure will all result in a decreased urine SG In renal failure (acute or chronic) the kidneys lose the ability to concentrate...

Renal transplant evaluation

MAG3 renography is non-nephrotoxic and a vital tool in the assessment of renal transplant patients. Clinical applications include Pre-transplant evaluation of renal function and drainage in the potential living related donor In the immediate post-transplant period, serial MAG3 studies can help distinguish between a variety of potential pathologies Within the first 4 weeks, renography demonstrating no tracer uptake is usually indicative of a renal perfusion disorder (renal artery stenosis or...

Stones

Certain drugs (e.g., cyclophosphamide) False-positive tests occur due to contamination. False-negative results are usually due to Inadequate contact of dipstick with urine Increased urinary specific gravity Therefore leucocyte esterase in isolation is insufficient to diagnose a UTI, but in conjunction with positive urinary nitrites is strongly suggestive of infection. Its use should be confined to screening urine in the asymptomatic patient in the primary care setting.

Types of catheters

The choice of catheter depends on the precise purpose, since there is so much variability in catheter size, type of material, tip shape, and number of lumens see table 6.4. Short-term catheters can remain indwelling for up to 4 weeks Long-term catheters should be replaced every 12 weeks Size Measured according to the Charriere French (F) gauge, where 1F 0.33 outer diameter. A size 12F catheter will have an outer diameter of 4 mm For most standard purposes a size 14-18F is adequate Size of...

Uss

CT scan (pre and post contrast to assess enhancement) Chest X-ray or CT scan of lung Consider bone scan if bone pain or hypercalcemia Renal cysts Usually incidental findings If simple (type I) no further investigations needed If complex (type II or greater) pre- and post-contrast CT scan is mandatory Risk of malignancy in Type III and IV is high (40-100 ) Classified according to Bosniak Type I simple cyst, no septa, no calcification Type II cyst with thin septa, no or fine calcification in the...

Vur

Retrograde flow of urine from the bladder into the upper urinary tract Prevalence between 1 and 2 of the general pediatric population More common in girls compared to boys till the age of 1 year, and then this relationship is reversed Males more likely to present symptomatically during the first year of life, while females present later (2-7 years) Hydronephrosis seen twice as often in boys as in girls Causes of VUR are classified as Primary anatomical abnormality resulting in incompetent...

Wbc

Pyuria is best diagnosed by microscopic examination of centri-fuged urine sediment. Normal urine may contain up to 2 WBC per HPF in men, and up to 5 WBC per HPF in women. Significant pyuria requires > 10 WBC per HPF. Fresh leucocytes (larger and rounder) are more suggestive of pathology, while old leucocytes (small and wrinkled) are usually seen in urine contaminated with vaginal secretions Large numbers of WBCs per HPF is highly specific for UTIs (especially if associated with hematuria),...

Split renal function

Renal Splitting

This is expressed as the ratio of the area under the renogram curves of the two kidneys obtained during the period 40 seconds to 2 minutes 40 seconds after tracer injection. The shortest transit time for filtrate in the Bowman's capsule to the renal pelvis is 2.5 minutes, and therefore it can be safely assumed that the MAG3 will not be found in the collecting system within 2.5 minutes of injection. The initial 40 seconds are excluded to prevent artifac-tual errors. The relative function in a...

Fractionated urine samples

In males, although MSUs are adequate, in certain clinical conditions it might be appropriate to take different aliquots of urine to aid localization of the UTI (e.g., diagnosis of prostatitis). Voided bladder 1 (VB1) first 5-10 mL of voided urine and represents urethral flora Voided bladder 2 (VB2) mid-stream urine and best correlates with bladder urine Voided bladder 3 (VB3) initial 2-3 mL of urine, containing expressed prostatic secretions (EPS), collected following prostate massage In...

Cysto Rpg Nephrostogram

Ultrasound scanning (USS), 80-87 advantages and disadvantages of, 86-87 in children, 83 contrast-enhanced, 82-83 Doppler-assisted, 117-118 color, 81-82, 117 duplex, 117 duplex penile, 127 for erectile dysfunction evaluation, 85 of hydroceles, 225 penile, 127, 261, 262 of testicular torsion, 225 indications for, 80-81 bladder outlet obstruction, 227 epididymitis, 224 penile cancer, 247 renal calculi, 235 testicular tumors, 249 interpretation of, 83-86 intraoperative, 86 for residual bladder...

E Urethral Pressure Profile Overview

Sufficient urethral pressure is mandatory for the maintenance of urinary incontinence. Urethral profile measurement (or urethral profilometry) is a technique used to record the intraluminal pressure changes within the entire length of the urethra. A satisfactory evaluation of urethral function can be made by a standard filling voiding bladder urodynamic study, such that urethral closure mechanism is considered adequate if no incontinence is demonstrated and inadequate if there is obvious stress...

Common abnormalities on cystometry

Abnormal results do not necessarily indicate pathology as inconsistent values may occasionally be noted in normal, asymptomatic patients and are of little clinical significance. Abnormalities noted in symptomatic patients are more consequential. Some characteristic findings associated with common abnormalities are described below. 1. Detrusor overactivity (see Fig 5.3) Characterized by phasic elevations of detrusor pressure over baseline during the filling phase, irrespective of the magnitude,...

Technique and interpretation

Cavernosography Penis

This study is usually performed as an outpatient procedure and no specific patient preparation is required. The only absolute contraindication is a previous history of contrast allergy. Two 19-22 G butterfly needles are inserted into the corpora. Care must be taken to avoid perforation of the urethra An erection is induced by an intracorporeal injection of 1020 g of prostaglandin Ej One of the needles is used to record intracavernosal pressures. A record is made of any increase in pressure up...

Mag3 Renal Scan Interpretation

Mag3 Obstruction

The shape of the renogram curve (following subtraction of background activity) is dependent on 1. MAG3 uptake from blood into kidney 2. MAG3 elimination from kidney into bladder Classically, the normal MAG3 renogram curve has three phases (see figure 4.1) The first phase steep upward rise following intravenous contrast injection this is indicative of the speed of tracer injection and its delivery to the kidneys (i.e., renal vascular supply) The second phase a more gradual slope which represents...

Urinary Acidification

A urinary pH that never falls below 5.8 is suggestive of renal tubular acidosis RTA The normal renal response to acidemia is to Reabsorb all filtered bicarbonate Increase hydrogen excretion primarily by enhancing the excretion of ammonium ions in urine Any inability of the renal tubules to perform these functions leads to a metabolic acidosis which typically Is a normal anion gap hyperchloremic metabolic acidosis Occurs as a consequence of either net retention of hydrogen chloride or its...

A Ureteropelvic junction obstruction UPJO

Classically identified in young women age 20-40 Type, severity, and location of the pain may vary Usually present with a dull ache in the loin worsened after drinking fluids Loin pain may be atypical in nature often mistaken for other non-renal pain Associated nausea and emesis Costovertebral angle tenderness on examination 1. Urine dipstick usually will be normal 3. USS to assess hydronephrosis but not accurate for diagnosing UPJO 4. IVU may help determine degree of obstruction and suggests...

Fbc

Often a lymphocytosis and oesinophilia Hyperkalemia, hyponatremia due to l mineralocorticoid T Urea, T calcium, T LFTs Hypoglycemia Cortisol levels low lt 100 nmol L random measurements of little use Aldosterone may be low normal range 111-860pmol L ACTH level gt 80 ng L Tetracosactide 250 g given im or iv at time 0 Measure plasma cortisol at time 0, 20, and 60 min A normal response should show cortisol increase to gt 550 nmol L Depot tetracosactide 1 mg at time 0 Plasma cortisol measurement at...

Kub

Helpful in documenting the number, size, and location of stones Radiopacity may provide information regording stones type Will identify calcium stones gt 1-2 mm in diameter Will miss most uric acid and some cystine calculi Will identify nephrocalcinosis seen in hyperparathyroidism, primary hyperoxaluria, renal tubular acidosis, or sarcoidosis Useful as a screening tool for hydronephrosis or stones within the kidney or renal pelvis Provides information on renal parenchyma in an obstructed...