Retention of urine Retention of urine is either acute or chronic Acute retention :- causes -Bladder outlet obstruction - Urethral stricture -Postoperative - Meatal ulcer with scabbing(in the male child) - Multiple sclerosis - Retroverted gravid uterus -Spinal anasthesia - Blood clot in the bladder - Urethral stone - Acute urethritis or prostatitis or abscess - Phimosis - Blood clot in the bladder - Rupture of the urethra -Neurogenic (injury or disease of the spinal cord) - Anal pain (haemorrhoidectomy) - Certain drugs(anticholinergic , nasal decongestants, antihistaminic compounds) clinical features :- -no urine passed for several hours -The bladder may be visible and is tender to palpation & dull to percussion

Treatment 1- Placement of a Foley catheter is the treatment of choice. 2- Difficult catheterisation . If the catheter does not enter the bladder easily ,percutaneous suprapubic cystotomy should be performed for temporary relief of urinary retention chronic retention; - - Chronic retention differs from acute retention in that the distension of bladder is almost painless - these patients are at risk of upper tract dilatation because of the high intravesical tension due to the large residual urine and the high resting bladder pressure

Urinary incontinence Classification of incontinence :is based on clinical symptoms 1- stress incontinence (genuine stress incontinence, urethral incontinence) is defined as the involuntary loss of urine during physical effort that is not caused by a bladder contraction. -it is much more in women & occurs in the upright position. - Maneuvers that commonly elicit stress incontinence include coughing, lifting, straining,& laughing. -The amount of urine lost is usually small ,unless a bladder contraction is precipitated at the same time. - Stress incontinence is unusual in nulliparous women & becomes more prevalent as parity increases.

Stress incontinence is classified into 3 types :- - type I stress incontinence :- results from a defect in the pelvic support of the bladder neck. - type II stress incontinence :- results from a defect in the pelvic support of both the bladder neck & urethra. - in both type I & type II, increased intraabdominal pressure causes hypermobility of the bladder neck or urethra. - type III stress incontinence (sphincteric insufficiency) : - here there is no urethral hypermobility, but an intrinsic urethral defect is the cause of incontinence. - this type may be caused by trauma , denervation, multiple surgical procedures, radiation therapy, or postmenopausal atrophy.

- Urge incontinence is loss of urine associated with marked urinary urgency. -overflow (false) incontinence (paradoxical incontinence) :- it results from chronic urinary retention. The patient leaks urine episodically and never voids normally. -total incontinence :- refers to constant diurnal & nocturnal incontinence without normal voiding . This type may be seen after obstetric or surgical injury to the female urethra , with epispadias in children, & following radical prostatectomy in male patients - true incontinence:- the patient may lose urine warning; the more obvious causes include exstrophy of the bladder, epispadias, vesicovaginal fistula , & ectopic ureteral orifice . Injury to the urethral smooth muscle sphincters may occur during prostatectomy or childbirth.

BLADDER STONES A primary bladder stone is one that develops in sterile urine; it often originates in a kidney & passes down the ureter to the bladder, where it enlarges. A secondary bladder stone occurs in the presence of infection, outflow obstruction, impaired bladder emptying or a foreign body such as non- absorbable sutures, metal staples or catheter fragments. Composition & cystoscopic appearance most vesical stones are mixed but have one component in excess and assume the appearance of that variety. Types of vesical calculi :- Oxalate calculus is a primary calculus ,usually it is solitary, its surface is uneven & sometimes has spines, its colour is usually dark brown or black because of the incorporation of blood pigment on to it. Uric acid and Urate calculi are round or oval ,smooth,& vary in colour from pale yellow to light brown, they may be single or multiple. Cystine calculus occurs only in the presence of cystinuria & is radio- opaque owing to its high sulphur content. Triple phosphate calculus is composed of an ammonium, magnesium, & calcium phosphates & occurs in urine infected with urea-splitting organisms. It is dirty white in colour. - A bladder stone is usually free to move in the bladder

Incidence:____ Male : female --- 8:1 CLINICAL FEATURES Incidence:____ Male : female --- 8:1 Frequency is the earliest symptom,& there may be a sensation of incomplete bladder emptying. Pain is usually occurs at the end of micturition & is referred to the tip of the penis or to the labia majora .the pain is worsened by movement. - in young boys, screaming & pulling at the penis with the hand at the end of micturition are indicative of bladder stone. Haematuria is characterised by the passage of a few drops of bright-red blood at the end of micturition, & is due to the stone abrading the vascular trigone. Interruption of the urinary stream is due to the stone blocking the internal meatus Urinary infection is a common symptom. Diagnosis: rectal or vaginal examination is usually normal; sometimes a large stone is palpable in the female. G.U.E usually reveals microscopic haematuria pus or crystals typical of the stone. K.U.B in most patients, the stone is visible. Sonography Excretory urography( E.U) if the stone is radiolucent, a filling defect may be visualised on IVU. Cystoscopy

TREATMENT In most patients, the cause of the underlying stone should be sought & treated.this may include bladder outflow obstruction plus infection and incomplete bladder emptying in patients with neurogenic bladder dysfunction. A. Perurethral Litholopaxy :through cystoscopic lithotrite a stone of < 2 cm can be grasped & crushed. - contraindications to perurethral litholapaxy 1- urethral stricture 2- contracted bladder 3- patients below 10 years of age 4- a very large stone > 2 cm. B. Hydraulic lithotripsy & ultrasonic lithotripsy for stones > 2 cm. C. Suprapubic lithotomy; removal of the stone through a suprapubic incision. D. Percutaneous suprapubic litholapaxy; this done if perurethral litholapaxy is not possible due to a narrow urethra. E. Extracorporeal shock wave lithotripsy(ESWL).

DIVERTICULUA OF THE BLADDER Diverticula are either acquired or congenital (rare). Most vesical diverticula are acquired & are secondary to either obstruction distal to the vesical neck or the upper motor neuron type of neurogenic bladder. increased intravesical pressure causes vesical mucosa to herniate itself between hypertrophied detrusor muscle bundles, so that a mucosal extravesical sac develops. Often this sac lies just superior to the ureter& causes vesicoureteral reflux. Vesical diverticulum is most frequently diagnosed incidentally by Cystoscopy or urinary tract imaging The presence of a diverticulum is not an indication for diverticulectomy unless symptoms are present. Complications: -1Recurrent urinary infection 2- neoplasm(< 5%) 3- bladder stone 4- hydronephrosis &hydroureter (rare)

An uninfected diverticulum of the bladder usually causes no symptoms. Clinical features: An uninfected diverticulum of the bladder usually causes no symptoms. The patient is nearly always male (95 %) & over 50 years of age. Haematuria (due to infection , stone or tumor). Recurrent urinary tract infection symptoms. Diagnosis: 1- Ultrasonography - 2IVU 3 - Retrograde cystography 4 - Cystoscopy

The causes are as follows Indications for operation Operation is necessary only for the treatment of complications. Treatment: Combined intravesical and extravesical diverticulectomy is the standard operation. VESICAL FISTULAS : Vesical fistulas are common. The bladder may communicate with the skin, intestinal tract, or female reproductive organs. The primary disease is usually not urologic. The causes are as follows 1- primary intestinal disease diverticulitis .( % 60-50) cancer of the colon(20-25%) Crohn ‘s disease (10%) - 2 Primary gynecologic disease *pressure necrosis during difficult labor advanced cancer of the cervix 3 – Treatment for gynecologic disease following hysterectomy, low cesarean section or radiotherapy for tumour. 4 - Trauma

Types of vesica! fistu!ae 1 ) Vesicovaginal fistula 2) vesicointestinal fistula 3 ) Vesicoadnexal fistula 4) vesicocutaneous fistula Treatment of 1) Vesicovaqinal fistula Small V.V.F sometimes respond to endoscopic fulguration of the fistula tract. Larger fistulas require some type of surgical procedure. Repair may be either by the transvaginal or trans abdominal route.

2) Vasicointestinal fistula If the lesion is in the rectosigmoid, treatment consists of proximal colostomy. When the inflammatory reaction has subsided, the involved bowel may be resected, with closure of the opening in the bladder . The colostomy can be closed later. if the lesion is the small bowel ,treatment consists of bowel resection & closure of vesical defect