1. Genitourinary Phase 2 Patrick King
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2. Aims
To cover aetiology, presentation, diagnosis and treatments of common urological problems such as: UTI, AKI, chronic renal failure, BPH and prostate cancer  
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3. Structure of urinary tract
Purpose of the UGS – to transport, hold and void urine at will
4 main parts of urological system:
Kidney – not too much detail, blood supply from the aorta (?), outer cortex, inner medulla – urology starts around the pelvis
Ureter – path of the ureter – from PUJ, over psoas muscle and “along the tips of the lumbar transverse processes, over the pelvic brim and iliac vessels, into the bladder at PVJ. Innervated by T12 to L2 (cause of pain distribution – loin to groin)
Bladder – sits down in the pelvis, attached postero-inferiorly and therefore expands upwards. Innervated by ANS. Held closed by 2 sphincters – internal – involuntary control, external – voluntary.
Urethra - 5cm in females, 20cm in males. Males is in 3/4 parts – (pre-prostatic), prostatic, membranous, spongy/penile.
Important facts of UGS - Lined almost entirely by transitional epithelium (psuedostrat. Columnar at the end) – distensible
Within the retroperitoneum.
Proximal to the internal urethral sphincter it contains no valves – UVJ is a functional valve
Sterile environment
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4. Lower Urinary tract infection
E.Coli, Klebsiella spp., proteus spp.,enterococci spp., staphylococcus saprophyticus
Symptoms: suprapubic pain, dysuria, frequency, foul smelling urine, nocturia, incontinence, fever, delirium
Investigations: ?
Treatment: Nitrofurantoin or trimethoprim
Recurrent UTI (>=3 UTIs in a year) warrants investigation – renal ultrasound, cystoscopy, KUB-XR
AKA cystitis, water infection
Anything distal to UVJ is lower urinary tract.
Upper graph is incidence of UTI, lower is prevalence of asymptomatic bacteriuria
Investigations: Urine dipstick, MSU
Recurrent UTI may be due to structural abnormality, renal stones, VUJ reflux, carcinoma.
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5. Upper UTI
Cause: ascent of LUTI, obstruction, bladder dysfunction Symptoms – “loin to groin” pain, fever/rigors, vomiting, lower UTS, haematuria. Unwell. Investigation – U&Es, urine sample, catheter, CTKUB, blood cultures Treatment – ABCDE, rehydration, IV antibiotics, drain hydronephrosis e.g. percutaneous nephrostomy/ catheter
AKA pyelonephritis, ascending UTI
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6. Acute Kidney Injury
Cause: split into pre-renal, renal and post-renal Presentation: 1st – reduced urine output (<0.5ml/kg) 2nd – raised creatinine, urea, K+, ↓eGFR 3rd – confusion, vomiting, overload Treatment: pre-renal - ? Renal – biopsy, steroids, removal, dialysis Post-renal - ?
Anything that acutely damages the kidney AKA acute renal failure
Pre-renal: hypoperfusion of the kidney
Renal: glomeluronephritis, vasculitis, drug toxicity
Post renal: obstruction
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7. Chronic renal failure
Cause: Diabetes, hypertension, old age, drugs Stage 1-5 depending on eGFR, 1/2 very common (1/10)
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8. The prostate Peripheral zone – site of most cancers (75%)
Transitional zone – grows throughout life in response to testosterone – causing BPH, site of 20% of cancers
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9. Benign prostatic hyperplasia
The prostate grows throughout life in response to testosteroen. It doubles in size every 4.5 years between 31 and % at 90 will have symptoms. Symptoms: ? Can cause acute/chronic retention – catheterise Ask about cancer symptoms, DRE Treatment: alphablockers e.g. doxazocin, 5-alpha-reductase inhibitors e.g. finasteride, TURP
Symptoms: frequency/nocturia, hesitancy, poor flow, terminal/post-mic dribble, straining
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10. Prostate cancer
80% of men in 80s have prostate cancer but only causes 13% of all cancer deaths. Symptoms: as before + bony pain, weight loss. PSA – 1000 screened: how many deaths prevented? how many false positives? Investigation – TRUS-prostate, radioisotope/MRI Treatment – watchful waiting & monitor anti-androgen therapy prostatectomy/radiotherapy – complications? 1
15% of cancers wont have a raised PSA
Causes of a raised PSA – ejaculation in the last 48 hours, DRE in the last week, UTI or prostatitis, BPH, catheterisation.
Complications of prostatectomy are incontinence and erectile dysfunction
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11. Quiz?
Which other structure in the retroperitoneum may have pathology that mimics upper UTI and needs urgent treatment?
Why do middle aged women have more UTIs?
A 120kg man on the ward has a urine output of 45mls in the last hour. Does this worry you?
Name two hormones produced/activated in the kidney.
A patient develops AKI 1 day post-op. What are 3 possible causes?
What 3 areas of the ureter provide anatomical narrows likely to stop stones?

12. Quiz? Management of an AKI patient with a K+ of 7.9.
What two structures may be damaged in a prostatectomy and what complications must the patient be warned of?
A 75 year old man comes in with chronic retention. Name one examination, one investigation and one intervention that should be done soon?
Is PSA a good screen for prostate cancer?