General Urology

General Urology

Urology is the branch of medicine that specializes in treating various conditions involving the urinary tract (kidney, ureter, bladder, prostate (only in males), and urethra)  as well as the disorders of male reproductive system (penis, testis and its surrounding structures) and adrenal lesions.

Constellation of symptoms related to bladder or bladder outlet is defined as LUTS. These are sub classified as voiding and storage symptoms.

Voiding symptoms (related to difficulty in the flow and therefore to the bladder outlet) includes hesitancy (difficulty to start), intermittency ( intermittent flow), poor stream , sense of incomplete bladder emptying and at times terminal dribbling.

Storage symptoms (related to overactive bladder) includes day time frequency, nocturia (getting up often in the night), urgency (severe urge to go toilet which is difficult to control) and urge incontinence (involuntary passing of urine).Patient can do a self-assessment using an IPSS score sheet as well a OAB questionnaire.

These conditions are treatable using medications and if necessary surgical interventions.

This is non-cancerous enlargement of the prostate happens with age is the most common cause of LUTS. The treatment for this condition is based on the symptoms rather than just prostatic enlargement. The treatment modalities included medications and medical therapy fails an endoscopic prostate operation (TURP) may be required.

This is a difficult condition to diagnose and treat. It involves a constellation of clinical conditions which may be due to infection or inflammation of the prostate gland. Patients often presents with pain in the groins, perineum, irritation in the urethra and, or pain of ejaculation.

After evaluation by an urologist, the patient needs treatment perhaps with antibiotics which is usually prolonged. A proportion of these patients have recurrence of the same symptoms and a small proportion may not get better and therefore needs combinations of medication to obtain optimum control of the symptoms.

Incontinence (involuntary loss of urine) though not life threatening is a devastating problem, resulting in embarrassment, loss of intimacy and social isolation.

This is defined as leakage associated with activity. This type of incontinence in men usually occurs after prostate surgery for cancer but occasionally may occur after other events such as injury, transurethral resection of the prostate (TURP) etc.

Leakage then occurs when the patient sneeze, cough, laugh, etc. If a man is diagnosed with stress incontinence, various successful treatments are available. In women, this condition is easily treated with a tape procedure.

Urge Incontinence

This condition is characterized by leakage of urine associated with sudden uncontrollable urge to pass urine. In this condition the patient gets an irrepressible urgency to urinate and inability to control the flow. Patients can also get urgency without incontinence. Variety of causes include: infection, prostatic obstruction, over activity of the bladder, stroke and others. Occasionally, urgency or urge incontinence can be the sign of a more sinister condition such as bladder cancer.

Urgency and urge incontinence need to be evaluated by a physician along with an analysis of the urine, and if needed urodynamics. Treatment depends on the cause and needs to be tailored to the patients’ need using a variety of methods includes medications, bladder drill and intravesical botox injection.

Overflow Incontinence

This is typically a constant leakage that occurs when a patient is unable to efficiently empty their bladder. Urine builds up and “spills” out, like a reservoir spilling over a dam. This can be due to obstruction (such as prostate or scarring in the urethra) and/or loss of bladder function or sensation. Treatments generally include catheters and/or surgery.

Collection of fluid around the testis in a sac is hydrocele. This can be assessed by clinical examination and confirmed by Ultrasound scan. Treatment is surgical which could be done as a day case.
Cyst with spermatic fluid found in the scrotum is spermatocele. They can form after vasectomy or occur without any known cause. These are removed if they cause symptoms through a small scrotal incision.
Testicular infection:
This is caused by bacterial or viral infection affecting either epididymis or testis or both. This is associated with pain and swelling of the testis and scrotum with or without fever. It needs be treated with pain killers, anti-inflammatory as well as antibiotics if necessary. In children and young adults one needs to differentiate it from acute torsion of testis and hence an urgent consultation with doctors is needed.
Testicular torsion:
In this condition the testicle twists and stays twisted in the scrotum rather than unwinding as one would expect. The twisting shuts off the blood supply to the testicle, which causes intense pain. The patient has sudden severe pain. This is a surgical emergency and needed immediate attention by a doctor and is treated by an operation.
Testicular cancer:
Onset of the painless swelling in the blood tests needs attention by a doctor as it could be a testicular cancer. It is diagnosed by a physical examination, ultrasound testis as well as blood tests. In the vast majority of patient, removing the testis through a Groin incision is required. Further treatments with chemotherapy or surgery may also be required.
Chronic scrotal pain:
A variety of conditions are responsible for this condition. This includes infective as well as non infective causes. It affects the quality of life of the patients and treatments are long and only partly successful. A consultation with a specialist is required.

Urinary stones could be found in the kidneys or in the ureters (tube that connects the kidney and the bladder). This is formed by precipitation of salts in the urine. Most commonly stones form from calcium, but they can also form from a variety of other materials including uric acid from gout. To note is that these stones are different from the stones formed in the urinary bladder which , inevitably is related to bladder outflow obstruction and urinary stasis.

Most small stones will pass spontaneously with hydration. Though the process is painful , it is accomplished with or without the help of a medication called Tamsulosin.

However stones more than 4 mm and especially more than 6 mm may not come out and hence will require other modalities of treatment. When stones are too large to pass, surgery is indicated to remove them. A ureteral stent may be required to relive blockage, or infection. A ureteral stent is a plastic tube placed between the kidney and the bladder with curly pigtails keeping them in place. In addition to reliving the blockage, it allows the ureter to dilate for a subsequent ureteroscopy.

Ureteric stones could be treated with ureteroscopy ( tiny camera passed through the urine pipe and into the ureter) and lithotripsy (breaking of stones which could be achieved by either LASER or lithoclast). In addition, these stones can also be treated with ESWL (External shock wave lithotripsy). This is a non-invasive technique of breaking the stones by targeting shockwaves on the stones using X ray guidance. Done over 30 min, this procedure minimally painful and will require sedation. Patients are expected to have blood in their urine and some soreness in the side where the lithotripter has touched the skin. Rare complications include bleeding around the kidney. This procedure would be appropriate for stones that are in the kidney or high in the ureter.

Ureteroscopy and laser lithotripsy:

A small scope is passed through the urethra into the bladder and up the ureter to the stone. The stone can be visualized directly and is broken up using a small laser fiber or Lithoclast. Stone fragments will be broken to dust or removed with a basket. Patients are most often left with a temporary plastic stent that is internal and is removed after few weeks (4-6) with a flexible cystoscope.

Percutaneous nephrolithotomy (PCNL):

This is especially useful for stones more than 1 cm in the kidneys as this technique has the best stone clearance rates. A hole to the kidney is made from the back for introducing a telescope. Subsequently the stone is broken with lithoclast and the fragments are then removed. A drain is placed which is removed after a day or two.

Reduction of stone recurrence

Patients who had urinary stones have a good chance of it coming back in future. Measures could be adopted to reduce the chance of recurrence. Hydration with about 3 litres of water (for an average adult) is the best method to reduce the chances of stones in future. Patients who had stones need a few blood tests as well as urine test which will be organised by the doctor.Minimising the salt, meat, chocolate, spinach, and cabbages would be a good idea. Fizzy drinks are best avoided. Appropriate calcium levels are essential and hence calcium restriction is no longer recommended.

Commonly found in men in their late fifties, this condition can rarely present in younger men as well. The patient needs a complete evaluation by a physician including physical evaluation (including examination of prostate) and blood tests. Special tests may be required in exceptional circumstances. Patients should also be evaluated for diabetes and cardiovascular issues.

The initial treatment includes counselling and medications ( PDE5 inhibitors e.g. sildenafil , tadalafil). If therapy fails, patients may need intra-cavernosal injection ( Small Injections in Penis) of drugs to induce erections.

Failure of all these therapies would then require implantation of artificial devices which could be a malleable or inflatable one. Details could be obtained from your physician.