Introduction to Clinical Training
Kyung Hee University Medical Center Department of Urology
비뇨기과
Urology
• Male, female urinary tract, male reproductive organs
• Surgical specialty
Voiding
• Dysuria: Painful urination
• Frequency: Frequent urination
• Urgency: Compelling urge to urination
• Tenesmus: Feeling of incomplete emptying
• Hesitancy: Trouble starting or maintaining a urine stream • Retention: Inability to voluntarily pass urine
• Incontinence [Stress/Urge]: Uncontrolled leakage of urine (Nocturnal enuresis or bed-wetting) • Stream [Small/Divided/Diminished force]
• Dribbling: Terminal release of drops of urine at end of micturition • Nocturia: Nocturnal frequency
• Hematuria [Total/Initial/Terminal] • Urethral discharge
Patient Presentation #1
• 60/M
•
입원 전날 술을 마신 이후 요의는 있으나 소변을 보지 못하여 응급
실 내원함 .
Patient Presentation #2
• 75/F, 2시간 전부터 발생한 급성 복통으로 ER 내원 • 30 년 Hysterectomy• V/S 150/75-84-20-36.0
• PE: Diffuse Rt abdominal pain and tenderness, CVA Td (-)
• Cr 1.5 mg/dl, CRP 0.99 mg/dl • Pain subsided with analgesics • IMP) AGE
How to void?
Campbell Walsh Urology 11 edition ch 70 p. 1685
Urinary retention (ICS)
• Acute Urinary Retention
• A patient is unable pass any urine despite having full bladder, which on examination is painfully distended and readily palpable or percussible.
• Chronic Urinary Retention
• This defined as a generally (but not always) painless and palpable or pe rcussible bladder, where there is a chronic high PVR where the patient experiences slow flow and incomplete bladder emptying. Overflow inco
ntinence can occur. Some individuals with retention present with impai red renal function and/or hydronephrosis.
AUA: PVR greater than 300ml that persisted for at least 6
Epidemiology
• More common in men
• Male:Female = 13:1
• Men with LUTS: 18-36/1000 men per year • Women: 3/100,000 women per year
• Increases with age
• Age ≥ 70: 10% • Age ≥ 80: 30%
Common etiologies
• Obstruction
• BPO, prostate or bladder ca, urethral stricture, urolithiasis, clot retention, phimosis, pelvic organ prolapse, constipation
• Neurologic
• Autonomic neuropathy, DM, CVA, spinal cord lesions
• Pharmacologic
• Anti-histamines, anti-cholinergics, anti-psychotics, sympathomimeitcs
• Infection
• Prostatitis, vulvovaginitis, urethritis, herpes simplex
• Trauma
AUA White Paper on Nonneurogenic Chronic Urinary Retention: Consensus Definition, Treatment Algorithm, and Outcome End Points. Stoffel et al. J Urol. 2017 Jul;198(1):153-160
Patient Hx and Physical examination
• Past medical history
• Prior history of retention, voiding symptoms • Treatment history of the lower urinary tract • Pelvic trauma
• Medication
• Physical examination
• Lower abdomen distention, tenderness
Evaluation
• Catheterization
• Decompression and diagnosis
• Laboratory work up
• CBC, Renal function work up, U/A, U/C • PSA
• Imaging studies
• KUB
• Abdomen sonography, transrectal sonography • Retrograde urethrography, cystoscopy
Evaluation
• Evaluation of voiding status
• Symptom questionnaires (IPSS, ICIQ) • Uroflometry and PVR
Management
• Bladder decompression
• Symptom relief, preserve detrusor function • Urethral vs Suprapubic
• Urethral stricture, previous prostate surgery, infection • More invasive, perivesical injury
• Long term, less uncomfortable, less risk of stricture and infection
• Indwelling vs intermittent catherization
Management
• After decompression
• Post-obstructive diuresis
• Increased urinary output, electrolyte imbalance • “Half-saline catch-up”
• Hematuria
• Irrigation
• Hypotension
• Due to rapid decompression and vasodilation? • Not relevant
Management
• Treating underlying cause after initial decompression
• BPO
• Medical treatment: alpha blockers, 5-alpha reductase inhibitor • Voiding try: Age, detrusor efficiency, amount of retention
• Surgical management: Transurethral resection of prostate (TUR-P), Holmium l aser enucleation of prostate (HoLEP)
• Operability
• Detrusor activity • Postoperative Cx
Patient Presentation #1
• 20/M
• 1
시간 전 부터 발생한 intermittent flank pain, hematuria
Urolithiasis
• Highly prevalent disease worldwide
• 7 to 13% in North America, 5-9% in Europe, 1-5% in Asia
• Depends on geographic, climatic, ethnic, dietary, genetic factors • Male > Female (2, 3 times more often)
• Caucasian > Hispanics > Asians > African-American • Uncommon before 20, peak in 40~60
• Climate: Fluid loss to perspiration, sunlight induced increase in Vit D • Obesity, Diabetes, Metabolic syndrome
Symptoms and Physical Examination
• Pain (Mild ~ Intense, Flank ~ Lower perineum)
• Renal colic
• Hematuria
• Nausea, vomiting, dysuria, urgency, fever
• Renal function deterioration
Differential diagnosis of flank pain
• Pyelonephritis
• Herpes Zoster
• Biliary colic, cholecystitis
• Intestinal obstruction, diverticulitis, appendicitis
• Aortic aneurysm
• Ectopic pregnancy, ovarian cyst rupture, torsion
• Etc…..
Workup
• Imaging study
• Non-contrast-enhanced computed tomography: Standard for diagn osis acute flank pain
• Contrast study: Planed stone removal, collecting system evaluation • Sonography: Solitary kidney, fever, doubt regarding Dx of renal colic • KUB, IVP etc
• Laboratory work up
• Cr, Uric acid, calcium, sodium, potassium, CBC, CRP • UA, UC
Management
• Renal colic management
• NSAIDS, opiates
• Renal decompression or primary ureteroscopic stone removal in anal gesic refractory colic pain
• Sepsis or anuria in obstructed kidney
• Emergency!!
• Decompression (Ureteral stent, or nephrostomy) • Anti-biotics treatment
Management
• Medical expulsive therapy
• ≤ 5 mm spontaneous expulsion
• Alpha blockers increase stone expulsion rate in distal ureteral stone s > 5 mm
Stone removal (ureter stones)
• Indications for active removal of ureteral stones are:
• Stones with a low likelihood of spontaneous passage; • Persistent pain despite adequate analgesic medication; • Persistent obstruction;
• Renal insufficiency (renal failure, bilateral obstruction, or single kidn ey)
• SWL (Shock wave lithotripsy)
Management of ureter stones
• Depends on
• Location • Stone size
SWL
• Less invasive (outpatient)
• Fewer overall complications compare d with URS or PCNL
• Success dependent on location, ston e size, stone component, pain contro l
• Steinstrasse, remnant stones Repe ated treatment, pain
• Tissue effect (renal hematoma, dysrh ythmia, liver spleen hematoma, bow el perforation) Infection
URS (Semi-rigid, flexible)
• More definitive treatment • Larger stones than SWL
• Admission and anesthesia • May need ureteral stenting
• Ureteral injury (stricture, avulsio n), retrograde repulsion into kidne y
Stone removal (renal stones)
• Indications for the removal of renal stones, include:
• Stone growth
• Stones in high-risk patients for stone formation • Obstruction caused by stones
• Infection
• Symptomatic stones (e.g., pain or hematuria); • Stones > 15 mm
• Stones < 15 mm if observation is not the option of choice; • Patient preference
• Comorbidity
• Social situation of the patient (e.g., profession or travelling); • Choice of treatment
Management of renal stones
• Depends on • Location • Stone size • Patient preference • Difficult SWL• Steep infundibular-pelvic angle • Long calyx
• Long skin-to-stone distance • Narrow infundibulum
• Shock wave-resistant stones (calcium ox alate monohydrate, brushite, or cystine).
RIRS
• Minimal invasive intrarenal surgery
• Learning curve
• Expensive equipment and cost, hi gh maintenance cost
• Increased radiation exposure
• Ureter injury and ureteral stenting • Longer surgery time for larger sto