1. WINTER IN ALEXANDRIA

2. Acute Urinary Retention Chronic Urinary Retention
Definition
Causes according to age & sex
Diagnosis (history, exam. Investigations)
AUR VS Anuria
Treatment

3. Hydronephrosis………
Pyonephrosis
Infected hydronephrosis
Definition, Causes,
Clinical picture
Imaging
D.D. of a renal Mass?
Treatment of
Hydronephrosis
Infected hydronephrosis
Pyonephrosis

4. Hematuria (symptom & sign)
Painless, Painful
Upper UT
Lower UT
Causes
Congenital,
Acquired
Diagnosis
Treatment (General, Specific)

5. Evaluation of Renal Function
Lab
Imaging
Overall renal function
Split renal Function
Acute renal Failure
Pre renal
Renal
Post renal (Obstructive)
Management

6. Renal Calculi
Primary, Secondary
Stone composition
Radio opaque , Lucent
Evaluation
Imaging
D.D. in KUB
Treatment
Medical ….. Dissolution
Interventional
SWL…PNL…Open Surgery

7. Ureteric Calculi
Treatment Options Depend on:
Level
Size
Degree of obstruction
Presence of UTI
Pain severity & Tolerance
Medical
Interventional:
SWL
Ureteroscopy
Surgery

8. Bladder Stones
Primary
Secondary
Imaging
DD
Treatment
No medical Treatment
Interventional:
Endoscopic crushing
Surgery
? SWL
RX of the cause

9. BPH
Clinical picture
(symptoms, signs…complications)
Is it BPH or Ca Prostate?
DRE….PSA…..TRUS Biopsy
Imaging
KUB? IVU? U/S? Others?
Associated pathology
DD: other causes of bladder
Outlet obstruction
Treatment:
Reassurance?
Medical…(non specific… specific)
Surgical….indications
TURP
Open
Laser

10. Prostate Cancer
Disease of old age
Clinical picture
LUTS … non specific
Symptoms of metastasis:
Bony pains,..LL edema,…
Fatigue, loss of WT
(DRE…PSA… TRUS biopsy)
Spread (local, lymphatic, blood borne)
Staging
Grading
Imaging (KUB,IVU,U/S)
Metastatic Survey:
Bone scan ….Chest X-Ray

11. Treatment
Depends on stage
Organ confined disease: (Potentially curable)
R. Prostatectomy….R. Radiotherapy
Locally advanced Disease (extra-prostatic):
Radiotherapy
Metastatic Disease:
Hormonal (endocrine) Treatment
Orchiectomy
LHRH agonists
Anti-androgens
Oestrogen

13. Bladder Cancer
Epidemiology:
Incidence, age, sex, …
Etiological factors
Gross Pathology (papillary,
solid)
Histopathology
Staging .. (TNM):
Superficial (Tis, Ta, T1)
Infiltrating (T2..T3)
Locally advanced ….T4
Metastatic (N, M)
Grading
Spread

14. Clinical Picture:
Symptoms
LUTS …Hematuria…..Necroturia
S.P.pain
Symptoms of metastasis
Signs:
BEUA…No mass…or .mass (mobile or fixed)
S.P. mass?
Lab: urine cytology
Imaging:
KUB, IVU, U/S..,CT
Cystoscopy & Biopsy (corner stone in diagnosis)

16. Treatment
Depends on stage
Superficial Bl Ca
TUR….Intravesical adjuvant therapy …. Follow up
Infiltrating Bl Ca…..
R. Cystectomy with urinary diversion
Locally advanced or metastatic
…Palliative treatment
Palliative surgery…..Radio-chemotherapy

17. Renal Pelvic Tumor ( 10% of R. Trs)
(Urothelial)
Histology
Presentation
Lab: (Cytology)
Imaging:
Filling defect within contrast in the renal pelvis
For D.D,
Confirmation by U/S…CT.
Uretero-Renoscopy
Treatment:
R.Nephro-ureterectomy with removal of cuff
Of the bladder mucosa around the homolateral UO

19. Renal Cell Carcinoma
85% of all renal tumors
Age & sex
Clinical Picture:
Asymptomatic....accidentally discovered
Pain , Mass, Hematuria
Paraneoplastic Syndrome
Metastasis
Signs
Gross pathology
Histopathology
Spread
Venous extension

20. Treatment:
The only effective treatment is surgery:
R. Nephrectomy for localized disease
Metastatic disease:
? Palliative nephrectomy….Immunotherapy
Imaging:
KUB, IVU, U/S
CT (gold standard)
Metastatic survey

22. URINARY RETENTION

24. ACUTE URINARY RETENTION (AUR)
One of the common clinical emergencies
Can present to any practicing physician
Definition:
Inability to void in spite of the presence
of a full bladder
Aetiology:
Disturbance of the evacuation
function of the bladder:
*Failure of effective detrusor
contraction
*Bladder outlet obstruction

25. Failure of effective detrusor contraction:
Neurological lesion interrupting detrusor innervation,
the micturition reflex or its higher control :
(cortical, brain stem, spinal cord or cauda equina
lesions)
Traumatic
Vascular
Neoplastic
Bladder outlet obstruction (infra-vesical obstruction)
Anatomy Pathology
Bladder neck …………………… (stone, tumor,.)
Prostate …………………………. (BPH,.. PCa,…)
Urethra……………………… (stone, Stricture, valve...)
External meatus …………………. Meatal stenosis
(encrustation)
Aetiology of AUR (cont.)

26. Drugs:
Parasympatholytics …detrusor hypotonia
Alpha-adrenergic agonists.. increased
tone of BN& proximal urethra
Beta-adrenergic agonists…detrusor
hypotonia
Post-operative:
Following….ano-rectal, pelvic & obstetric
interventions
Aetiology of AUR (cont.)

27. Aetiology of AUR correlated to age & sex:
AUR in males over 50 :
Benign Prostatic Hyperplasia (BPH)
Prostate Cancer
Other causes…
Predisposing factors of AUR related to BPH:
*Infection:
BPH complicated by prostatitis
*Congestion:
prolonged inhibition of voiding desire
exposure to cold
sustained sexual arousal
*Prostatic infarction
*Bladder decompensation
BPH

28. AUR in middle aged males:
-Stone impaction in B.N. or
urethra
- Urethral stricture with oedema
- Urethral trauma (rupture)
Other causes…
extravasation
stricture

29. AUR in young boys:
Posterior urethral valve
( AUR on top of chronic)
Meatal stenosis
(with infection/encrustation)
valve

30. AUR in females:
Generally uncommon
- Neurogenic
- Urethral & vulval
tumors
- Hysterical

31. Chronic Urinary Retention
A condition characterized by persistent failure of
complete bladder evacuation at the time of voiding
Causes
weak detrusor contractility
(usually neurogenic)
Chronic bladder outlet obstruction

32. Pathology of chronic UR
Same causes of AUR
Gradual building up of residual urine over time
Is it significant PV residual?
How to assess?
The result will be pathologically increasing bladder
Capacity
Normal Bladder Capacity= 300 -500 ml
In ch. UR may reach 1-2 or litres more

33. Eventually the picture will be:
Large UB with thinned out wall…
(poor contractility)
Large amount of post-void residual
urine with stasis
Increased susceptibility to Rec. UTI &
bladder Lithiasis
AUR on top… may occur
Over-flow incontinence
Bil. hydro-uretero- nephrosis….
Renal insufficiency

34. Diagnosis of AUR
Clinical picture:
*Recent onset of inability to void
*Suprapubic & urethral pains
(?misleading complaint)
Examination: reveals evidence of a full
Bladder (inspection, palpation & percussion)
However, in obese or muscular individuals,
clinical examination may be equivocal
To confirm:
*Insert a urethral catheter
*Abdominal sonography
Further evaluation & investigation to reveal
the under-lying cause are done after bladder
evacuation

35. Acute Retention versus Anuria
Definition
Symptoms &recent history
Abdominal examination
Imaging (ultrasound)
Urethral catheter
Renal function tests

36. Treatment of AUR
Immediate treatment:
Insert a urethral catheter to evacuate the bladder
Rules of proper catheterization
- Use a sterile packed catheter of appropriate size
- Use sterile gloves
- Paint the ext. genitals with an antiseptic solution
- Inject a lubricant (with local anaesthetic gel )
into the urethra
- Gently advance the catheter into the urethra
till urine comes out.
- Never push against resistance
Failure of catheterization?!
A suprapubic cystostomy is done under local
analgesia

39. Further evaluation is done to reveal
the cause of AUR:
- Lab
- Imaging
- Endoscopic.
Definitive treatment will be that of the
underlying cause
Definitive treatment