UROLOGY — A Brief Introduction

Dr. Samuel Osaghae, MBBS (Benin), FWACS, FMCS (Nig), FRCS, FEBU (Urology), Senior Lecturer and Honorary Consultant Urological Surgeon, School of Medicine, University of Benin, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

SCOPE
• Meaning of Urology
• Urinary system in males
• Urinary system in females
• Urinary system in children
• Genital system in males
• Genital system in females (Obstetrics & Gynaecology)
• Common Diseases in Urology
• Kidney Diseases
• Ureter Diseases
• Bladder Diseases
• Prostate Diseases
• Urethra Disease
• Testes and Penis related Diseases
• Adrenal Gland
• Common Investigations (Diagnostics Test) in Urology
• Examination & Management Practices of Urology Patients
• Pre-and Post-Operative Care of Urology Patients
• Questions for Reflection & Further Study
• Useful Tips

MEANING OF UROLOGY
Urology is a medical specialty that focuses on the diagnosis, treatment, and management of conditions related to the urinary tract system and male reproductive system. Urologists are physicians who specialize in urology and are trained to diagnose and treat various disorders of the kidneys, bladder, ureters, urethra, and male reproductive organs, including the testes, prostate, and penis.
Urologists are skilled in both medical and surgical techniques, and they provide care for both men and women. Some common conditions treated by urologists include urinary tract infections, kidney stones, bladder and prostate problems (such as bladder infections, urinary incontinence, and enlarged prostate), erectile dysfunction, infertility, and urological cancers (such as bladder, kidney, prostate, and testicular cancer).
Urologists employ various diagnostic methods, including physical examinations, laboratory tests, imaging studies (such as ultrasounds, CT scans, and MRIs), and specialized procedures (such as cystoscopy) to evaluate and diagnose urological conditions. Treatment options can range from medication and lifestyle modifications to surgical interventions, depending on the specific condition and its severity.
Urology plays a crucial role in maintaining urinary and reproductive health, and urologists work in collaboration with other medical specialists, such as nephrologists (who focus on kidney disorders) and oncologists (who specialize in cancer treatment), to provide comprehensive care to patients with urological conditions.

URINARY SYSTEM IN MALES
The urinary system in males, also known as the male genitourinary system, consists of organs and structures involved in the production, storage, and elimination of urine, as well as the production and transportation of semen. The key components of the urinary system in males include the kidneys, ureters, bladder, urethra, and accessory reproductive organs.

· Kidneys: The kidneys are two bean-shaped organs located on either side of the spine in the back of the abdominal cavity. They play a vital role in filtering waste products and excess fluids from the bloodstream to produce urine. The urine is then transported from the kidneys to the bladder through tubes called ureters.

• Ureters: The ureters are long, narrow tubes that connect the kidneys to the urinary bladder. They carry urine from the kidneys to the bladder by peristaltic contractions, which propel the urine forward.
• Bladder: The bladder is a hollow, muscular organ located in the pelvis. Its primary function is to store urine until it is voluntarily expelled during urination. The bladder has a capacity of approximately 400–600 milliliters in adults but can expand to accommodate larger volumes of urine if needed.
• Urethra: The urethra is a tube that serves as a conduit for urine to exit the body from the bladder. In males, the urethra also has a reproductive function as it carries semen during ejaculation. It extends from the bladder through the prostate gland and runs through the penis to its external opening, known as the urethral meatus.
• Accessory Reproductive Organs: In addition to the urinary system, males have accessory reproductive organs that play a role in the production and transport of semen. These include the prostate gland, seminal vesicles, and bulbourethral glands. The prostate gland surrounds the urethra just below the bladder and produces a fluid that helps nourish and protect sperm. The seminal vesicles produce a significant portion of the fluid that makes up semen, while the bulbourethral glands secrete a lubricating fluid that aids in the passage of semen through the urethra.

Together, these structures make up the male urinary system, which is responsible for the elimination of waste products and maintenance of fluid balance, as well as the production and transport of sperm for reproduction.

URINARY SYSTEM IN FEMALES

The urinary system in females, also known as the female genitourinary system, is responsible for the production, storage, and elimination of urine. It consists of several organs and structures that work together to perform these functions. The key components of the urinary system in females include the kidneys, ureters, bladder, and urethra.

Unlike the male urinary system, females do not have accessory reproductive organs directly associated with the urinary system. However, the urethra is located within the pelvic region, which is anatomically close to the reproductive organs, such as the uterus, ovaries, and vagina.

The urinary system in females plays a crucial role in maintaining fluid balance, eliminating waste products from the body, and preventing urinary tract infections. It works in coordination with other systems, such as the reproductive system and the nervous system, to regulate urine production and control the timing of urination.

In females, the urethra is shorter than in males and is located in close proximity to the vaginal opening. Its main function is to carry urine from the bladder out of the body during urination.

URINARY SYSTEM IN CHILDREN

The urinary system in children is similar to that of adults, consisting of organs and structures involved in the production, storage, and elimination of urine. However, there are some differences in size and development that are specific to children.

Children’s urinary systems undergo developmental changes as they grow. Newborns and infants have relatively immature kidneys and may have limited kidney function initially. As they age, the kidneys mature, and their filtering and concentrating abilities improve.

It is important to note that children may experience specific urinary issues or conditions that are more common in pediatric populations, such as urinary tract infections, bedwetting (enuresis), vesicoureteral reflux (a condition where urine flows backward from the bladder into the ureters or kidneys), and congenital abnormalities of the urinary system.

Regular monitoring, proper hydration, and prompt medical attention for any concerning symptoms are important for maintaining the health of the urinary system in children. Pediatric urologists are specialized doctors who diagnose and treat urological conditions specific to children, ensuring their optimal urinary health.

GENITAL SYSTEM IN MALES

The genital system in males, also known as the male reproductive system, is responsible for the production, storage, and delivery of sperm for reproduction. It includes both internal and external organs that work together to facilitate the process of fertilization. The key components of the male genital system include the testes, epididymis, vas deferens, seminal vesicles, prostate gland, bulbourethral glands, and penis.

• Testes: The testes, also known as testicles, are a pair of oval-shaped organs located within the scrotum, which is a sac-like structure outside the body. The testes produce sperm cells through a process called spermatogenesis and also secrete testosterone, the primary male sex hormone.
• Epididymis: The epididymis is a long, coiled tube located on the back of each testicle. It serves as a storage and maturation site for sperm cells produced in the testes. Sperm cells gain the ability to swim and fertilize an egg as they pass through the epididymis.
• Vas Deferens: The vas deferens, also known as the ductus deferens, is a muscular tube that connects the epididymis to the urethra. It serves as the pathway for sperm to travel from the testes to the ejaculatory ducts during ejaculation.
• Seminal Vesicles: The seminal vesicles are a pair of glands located near the base of the bladder. They secrete a fluid rich in fructose, prostaglandins, and other substances that provide energy and nourishment to sperm. The fluid from the seminal vesicles combines with sperm to form semen.
• Prostate Gland: The prostate gland is a walnut-sized gland situated just below the bladder, surrounding the urethra. It produces a milky, alkaline fluid that helps to protect and nourish sperm. This fluid is released into the urethra during ejaculation as part of semen.
• Bulbourethral Glands: Also known as Cowper’s glands, the bulbourethral glands are small glands located beneath the prostate gland. They secrete a clear, slippery fluid that lubricates the urethra and prepares it for the passage of sperm.
• Penis: The penis is the external organ of the male reproductive system. It consists of the shaft and the glans. The urethra, which carries both urine and semen, runs through the penis. During sexual arousal, the penis becomes erect, allowing for sexual intercourse and the deposition of semen into the female reproductive system.

The male genital system is responsible for the production of sperm, the transportation and mixing of sperm with seminal fluid to form semen, and the delivery of semen into the female reproductive tract during sexual intercourse. This allows for fertilization of the female egg and the initiation of the reproductive process.

GENITAL SYSTEM IN FEMALES

A detailed study of the female genital system is the subject matter of Obstetrics & Gynaecology.

KIDNEY DISEASES

Kidney disease, also known as renal disease or nephropathy, refers to any condition that affects the function or structure of the kidneys. It can range from mild to severe and can be acute (sudden onset) or chronic (long-term).

Congenital kidney diseases: Polycystic Kidney Disease, Renal agenesis, Congenital nephrotic syndrome.

Acquired kidney disease: Acute Kidney Injury, Infections (Pyelonephritis), Neoplastic (Benign Renal Cyst; Renal Cancer), Stones (Nephrolithiasis), Trauma (Renal injuries).

• Polycystic Kidney Disease (PKD): This is of two types: Autosomal Dominant Polycystic Kidney Disease and Autosomal Recessive Polycystic Kidney Disease. Both forms of PKD can lead to kidney enlargement, abdominal pain, blood in urine, urinary tract infections, high blood pressure, and kidney failure. Diagnosis is typically made through imaging studies, such as ultrasound, CT scan, or MRI, which can reveal the presence of multiple cysts in the kidneys.
• Renal Agenesis: This is condition in which one or both kidneys fail to develop. It can be unilateral (affecting only one kidney) or bilateral (affecting both kidneys). Unilateral renal agenesis often goes unnoticed because the remaining kidney can typically function normally. However, bilateral renal agenesis is a severe condition that is incompatible with life, as it results in the absence of both kidneys.
• Acute Kidney Injury (AKI): This is also known as acute renal failure, refers to a sudden loss of kidney function. It can occur due to various factors, such as severe dehydration, blood loss, infections, medications, kidney infections, obstruction of the urinary tract, or damage to the kidney tissue. AKI is characterized by a rapid decline in kidney function, resulting in an accumulation of waste products and imbalances in fluid and electrolytes.
• Kidney Stones: Kidney stones, or renal calculi, are solid deposits that form in the kidneys. They are typically composed of minerals and salts that crystallize and clump together. Kidney stones can be caused by various factors, including dehydration, certain medical conditions, dietary factors, and genetic predisposition. The size and location of the stones determine the severity of symptoms, which can include severe pain, blood in the urine, and urinary tract infections.

Symptoms of kidney disease can vary depending on the underlying cause and the stage of the disease. However, common signs and symptoms may include decreased urine output, swelling (edema), fatigue, loss of appetite, nausea, difficulty concentrating, and fluid and electrolyte imbalances.

Treatment for kidney disease depends on the specific cause and severity of the condition. It may involve medications to manage symptoms, control underlying diseases, or slow the progression of kidney damage. In advanced cases, dialysis or kidney transplantation may be necessary.

Preventing kidney disease involves maintaining a healthy lifestyle, managing underlying conditions such as diabetes and hypertension, staying hydrated, avoiding excessive use of over-the-counter pain medications, and regular monitoring of kidney function through routine check-ups and blood and urine tests.

URETER DISEASES

Congenital ureter diseases: Vesicoureteral Reflux (VUR), Ureteropelvic Junction Obstruction (UPJO), Ureteral Duplication, Megaureter, Ureteral Atresia and so on.

Acquired ureter disease: Ureteral Calculi, Ureteral Stricture, Ureteral Tumors, Ureteral Obstruction, Ureteral Injury and so on.

• Ureteropelvic Junction Obstruction (UPJO): This is a condition where there is a narrowing or blockage at the point where the ureter connects to the renal pelvis (the area where urine collects in the kidney). This obstruction can hinder the normal flow of urine from the kidney to the bladder, potentially causing urine to accumulate and leading to hydronephrosis (enlargement of the kidney) and impaired kidney function.
• Ureteral Duplication: This is a condition in which a person has two ureters draining a single kidney. It occurs during fetal development when the ureteral bud, which gives rise to the ureter, divides incompletely. Ureteral duplication can lead to various complications, such as increased susceptibility to urinary tract infections, urinary reflux, and urinary obstruction.
• Ureteral Calculi / Stones: When kidney stones are formed in the kidneys, they can travel down the ureters. When a stone becomes lodged in the ureter, it can cause severe pain and obstruct the flow of urine. Common symptoms include flank pain, blood in the urine, and urinary urgency.
• Ureteral Stricture: This condition refers to a narrowing or constriction of the ureter. This condition can occur due to various causes, including prior surgery, trauma, infection, or inflammation. Ureteral strictures can lead to urinary obstruction, hydronephrosis (enlargement of the kidney), recurrent urinary tract infections, and kidney damage.

BLADDER DISEASES

Common disease condition of the bladder: Urinary Tract Infections (UTIs), Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS), Bladder Cancer, Bladder Stones, Neurogenic Bladder and so on.

• Interstitial Cystitis: This is a chronic condition characterized by bladder pain and urinary urgency. The exact cause of IC/BPS is unknown, but it is believed to involve a combination of factors, including bladder inflammation, nerve dysfunction, and immune system abnormalities. Symptoms can vary but often include pelvic pain, increased urinary frequency, and a strong urge to urinate.
• Bladder Cancer: This condition occurs when abnormal cells in the bladder multiply and form a tumor. It is more commonly found in older individuals and is often associated with a history of smoking or exposure to certain chemicals. Symptoms of bladder cancer may include blood in the urine, frequent urination, pain during urination, and lower back pain.
• Neurogenic Bladder: This is a condition that results from nerve damage or dysfunction affecting the bladder. It can be caused by conditions such as spinal cord injury, multiple sclerosis, stroke, or nerve damage from diabetes. Neurogenic bladder can lead to problems with bladder control, resulting in symptoms such as urinary incontinence, urinary retention, frequent urinary tract infections, or difficulty emptying the bladder completely.

PROSTATE DISEASES

Common disease condition of the prostate: Benign Prostatic Hyperplasia (BPH), Prostatitis, Prostate Cancer, Prostatic Abscess, and so on.

• Benign Prostatic Hyperplasia (BPH): This condition is also known as prostate gland enlargement, is a common condition that affects many aging men. It occurs when the prostate gland grows in size, causing compression of the urethra and obstructing urine flow. Symptoms of BPH may include frequent urination, weak urine flow, difficulty starting and stopping urination, and the sensation of incomplete emptying of the bladder.
• Prostatitis: Prostatitis refers to inflammation or infection of the prostate gland. It can be categorized into several types, including acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis/chronic pelvic pain syndrome (CPPS), and asymptomatic inflammatory prostatitis. Symptoms can vary but often include pain or discomfort in the pelvic area, pain during urination or ejaculation, frequent urination, and urinary urgency.
• Prostate Cancer: Prostate cancer is a common cancer that affects the prostate gland. It typically develops in older men. Prostate cancer may not cause noticeable symptoms in its early stages, but as it progresses, symptoms can include urinary difficulties, blood in the urine or semen, erectile dysfunction, and pain in the pelvic area or bones.
• Prostatic Abscess: A prostatic abscess is a localized collection of pus within the prostate gland. It is usually caused by a bacterial infection that spreads to the prostate. Symptoms can include fever, chills, pelvic pain, urinary difficulties, and rectal discomfort. Treatment typically involves draining the abscess and administering antibiotics to clear the infection.

URETHRA DISEASES

Common disease condition of the urethra: Urethral Stricture, Urethritis, Urethral Diverticulum, Urethral Fistula, Urethral Caruncle, Posterior urethral valve, PUV and so on.

• Urethral Stricture: This refers to the narrowing or constriction of the urethra, which can impede the flow of urine. It can occur due to various factors, such as scar tissue formation from trauma, inflammation, infection, or previous surgical procedures. Symptoms of urethral stricture may include a weak urine stream, difficulty starting and stopping urination, frequent urination, urinary retention, and urinary tract infections.
• Urethritis: Urethritis is inflammation or infection of the urethra. It is commonly caused by bacterial or viral infections, such as sexually transmitted infections (STIs) like gonorrhea or chlamydia. Symptoms may include pain or a burning sensation during urination, frequent urination, discharge from the urethra, and urinary urgency.
• Urethral Diverticulum: Urethral diverticulum is a pouch or pocket that forms along the urethra. It occurs due to the weakening of the urethral wall. Urethral diverticula can cause symptoms such as pelvic pain, discomfort during sexual intercourse, urinary frequency, recurrent urinary tract infections, and difficulty emptying the bladder completely.
• Urethral Fistula: Urethral fistula is an abnormal connection between the urethra and another structure, such as the vagina or rectum. It can result from trauma, infection, or complications of surgery. Urethral fistulas can cause urinary leakage, recurrent urinary tract infections, and discharge from the abnormal connection site.
• Urethral Caruncle: Urethral caruncle is a small, fleshy growth or lesion that can develop at the urethral opening, particularly in postmenopausal women. It is often benign and noncancerous. Symptoms may include pain, itching, urinary discomfort, and occasionally bleeding.

TESTES & PENIS-RELATED DISEASES

• Hydroceles in Children: A hydrocele is a common condition in children where there is an accumulation of fluid around the testicle, leading to swelling in the scrotum. It occurs due to a communication problem between the abdomen and the scrotum, causing fluid to accumulate. In most cases, hydroceles resolve on their own within the first year of life. However, if a hydrocele persists beyond that time or causes discomfort, surgical intervention may be required to remove the fluid and repair the communication between the abdomen and scrotum.
• Undescended Testes (Cryptorchidism): Cryptorchidism refers to the condition where one or both testes fail to descend into the scrotum from the abdomen during fetal development. It is a common condition in newborn boys. Undescended testes may descend on their own within the first few months of life. However, if the testes do not descend spontaneously, treatment options include hormone therapy to stimulate descent or surgical placement of the testes into the scrotum (orchidopexy) to prevent potential complications and ensure normal testicular function.
• Congenital Absence of Vas Deferens (CAVD): This is a condition in which the vas deferens, the tube that carries sperm from the testes to the urethra, is absent. It is usually associated with cystic fibrosis, a genetic disorder. CAVD can result in infertility as the absence of the vas deferens prevents the transport of sperm. Assisted reproductive techniques, such as in vitro fertilization (IVF) with sperm retrieval, may be utilized to achieve pregnancy in individuals with CAVD.
• Varicoceles (Primary): Varicoceles are enlarged veins within the scrotum, similar to varicose veins that occur in the legs. They are the most common cause of male infertility and typically affect the left side of the scrotum. Varicoceles develop when the valves within the veins that help regulate blood flow become weak or malfunction, leading to pooling of blood. Treatment options for varicoceles may include surgical repair (varicocelectomy) or less invasive techniques, such as embolization, to improve fertility and alleviate symptoms.
• Hypospadias/Epispadias: Hypospadias and epispadias are congenital conditions that affect the opening of the urethra in males. In hypospadias, the urethral opening is located on the underside of the penis instead of at the tip, whereas in epispadias, the opening is on the upper side. Both conditions can vary in severity, and surgical correction is usually necessary to reposition the urethral opening to the tip of the penis and improve urinary function and appearance.
• Hydroceles in adults: This refers to the accumulation of fluid around the testicle, leading to swelling in the scrotum. Unlike hydroceles in children, hydroceles in adults are usually not associated with a communication problem between the abdomen and scrotum. They can occur due to various factors such as inflammation, injury, infection, or underlying medical conditions.
• Varicoceles (Secondary): Secondary varicoceles are enlarged veins within the scrotum that develop as a result of an underlying condition, such as an obstruction or blockage in the blood vessels. They are typically more common on the left side of the scrotum. Secondary varicoceles may be caused by factors such as tumors, kidney disorders, or previous surgeries.
• Torsion of Testes: Testicular torsion occurs when the spermatic cord, which provides blood supply to the testicle, twists, and restricts blood flow. It is a urological emergency and requires immediate medical attention. Torsion of the testes can cause severe testicular pain, swelling, and nausea. Surgical intervention is necessary to untwist the testicle and secure it in place to prevent further torsion and potential loss of the testicle.
• Erectile Dysfunction (ED): It refers to the inability to achieve or maintain an erection sufficient for sexual intercourse. It can have various causes, including underlying medical conditions (e.g., diabetes, cardiovascular disease), hormonal imbalances, psychological factors, or certain medications. Treatment for erectile dysfunction depends on the underlying cause and may involve lifestyle modifications, counseling, medications (such as phosphodiesterase-5 inhibitors), hormone therapy, or other specialized treatments.
• Fracture of Penis: A fracture of the penis refers to a tear or rupture in the tunica albuginea, the fibrous covering of the penis. It usually occurs during vigorous sexual activity or trauma to the erect penis. Symptoms include immediate pain, swelling, and the appearance of bruising. Surgical intervention is often necessary to repair the penile tissue and prevent long-term complications such as erectile dysfunction or curvature of the penis.
• Peyronie’s Disease: This is a condition characterized by the development of fibrous scar tissue (plaques) within the penis, leading to curvature, pain, and erectile dysfunction. The exact cause of Peyronie’s disease is unknown, but it is believed to involve an abnormal wound healing response.

ADRENAL GLAND DISEASES

The adrenal glands are a pair of small, triangular-shaped endocrine glands located on top of each kidney. They play a vital role in producing hormones that regulate various bodily functions, including metabolism, stress response, blood pressure regulation, and electrolyte balance. While many adrenal conditions can be managed with medications, there are certain surgical diseases that may require surgical intervention. Here are a few examples:

• Adrenal Tumors: Adrenal tumors can be either benign (non-cancerous) or malignant (cancerous). Surgical removal of adrenal tumors is often recommended, especially if they are causing symptoms, growing in size, or suspected to be cancerous. The surgical procedure may involve removing either the affected adrenal gland (adrenalectomy) or both glands (bilateral adrenalectomy) in certain cases.
• Adrenal Cortex Hyperplasia: Adrenal cortex hyperplasia refers to an overgrowth or enlargement of the adrenal cortex, the outer layer of the adrenal glands. This condition can be caused by various factors, such as certain genetic disorders or prolonged exposure to excess adrenocorticotropic hormone (ACTH). Surgery may be considered to remove the affected portions of the adrenal cortex or, in severe cases, the entire gland.
• Pheochromocytoma: Pheochromocytomas are rare tumors that develop in the adrenal medulla, the inner part of the adrenal glands. These tumors produce excessive amounts of adrenaline and noradrenaline, leading to symptoms such as high blood pressure, palpitations, and excessive sweating. Surgical removal of pheochromocytomas is typically recommended to alleviate symptoms and prevent potential complications.
• Adrenal Cortical Carcinoma: Adrenal cortical carcinoma is a rare and aggressive cancer that originates in the adrenal cortex. Surgery is the main treatment for localized adrenal cortical carcinoma, involving the removal of the affected adrenal gland and surrounding tissues. In advanced cases, additional treatments such as chemotherapy and radiation therapy may also be utilized.

It’s important to note that the specific surgical approach may vary depending on factors such as the size, location, and characteristics of the adrenal disease. Surgical procedures can be performed using open surgery, laparoscopic techniques, or robot-assisted approaches. The decision to pursue surgery and the choice of the surgical method are typically determined by a multidisciplinary team of specialists, including endocrinologists, urologists, and surgeons, who assess the individual patient’s condition and overall health.

COMMON INVESTIGATIONS (DIAGNOSTICS TEST) IN UROLOGY

The common diagnostic test in urology can be categorized into the following:

• Urine Test
• Blood Test
• Imaging Test
• Special Urology Test
• Telescopic Examination of Urinary Tract
• Biopsy

URINE TEST

• Urinalysis is a common diagnostic test that examines the physical, chemical, and microscopic properties of urine. It provides valuable information about the overall health of the urinary system. Urinalysis helps in the diagnosis and monitoring of various conditions, including urinary tract infections, kidney diseases, diabetes, and liver disorders. It is a non-invasive and relatively inexpensive test that provides valuable information to healthcare professionals. During urinalysis, a urine sample is collected and analyzed for various parameters. These include:
• — Physical properties: Urine color, appearance (clarity or turbidity), and specific gravity.
• — Chemical properties: pH level, presence of protein, glucose, ketones, bilirubin, nitrites, and leukocyte esterase.
• — Microscopic examination: Detection of red blood cells, white blood cells, epithelial cells, casts, crystals, and bacteria.
• Urine Culture: Urine culture is a laboratory test that aims to identify and determine the presence of bacteria or other microorganisms in a urine sample. It is primarily used to diagnose urinary tract infections (UTIs) and guide appropriate antibiotic treatment. During a urine culture, a urine sample is collected and incubated on specific culture media to allow the growth of any present bacteria. The cultured bacteria are then identified, and susceptibility testing is performed to determine which antibiotics are effective in treating the infection. Urine culture helps differentiate between various types of UTIs, such as lower urinary tract infections (cystitis) and upper urinary tract infections (pyelonephritis). It helps guide the selection of antibiotics based on the specific bacteria causing the infection and their sensitivity to different medications. This helps ensure appropriate treatment and reduces the risk of antibiotic resistance.
• Urine Cytology: Urine cytology is a diagnostic test that examines the cells present in urine under a microscope. It is primarily used to detect abnormal or cancerous cells in the urinary tract, including the bladder, ureters, and kidneys. During urine cytology, a urine sample is collected and processed in the laboratory to prepare a slide for microscopic examination. Urine cytology is particularly useful in the diagnosis of bladder cancer. It can help identify malignant cells shed into the urine by bladder tumors. However, it is important to note that urine cytology has limitations, and false-negative results are possible. Additional tests, such as cystoscopy and imaging studies, may be needed for a comprehensive evaluation of urinary tract abnormalities.

BLOOD TEST

• Prostate Specific Antigen (PSA): This is a blood test used to measure the levels of a protein produced by the prostate gland called prostate-specific antigen. PSA testing is commonly used in urology to screen for prostate cancer and monitor the progression of the disease. Elevated PSA levels may indicate the presence of prostate cancer, but it is important to note that PSA levels can also be elevated due to other factors, such as benign prostatic hyperplasia (BPH), prostatitis, or recent ejaculation. Further evaluation, including a prostate biopsy, is usually necessary to confirm the presence of prostate cancer.
• Urea, Electrolytes, and Creatinine: The urea, electrolytes, and creatinine blood test is a panel of tests that assesses the levels of urea, electrolytes (such as sodium, potassium, and chloride), and creatinine in the blood. These tests provide important information about kidney function and overall electrolyte balance. Urea is a waste product that is filtered by the kidneys, and elevated levels can indicate impaired kidney function. Electrolytes play a crucial role in maintaining the balance of fluids and conducting electrical signals in the body. Creatinine is a waste product generated by muscle metabolism, and its levels can be used to estimate kidney function. Abnormal results in these blood tests can indicate kidney disease or other conditions that affect kidney function.
• Male Hormone Profile (Testosterone): The male hormone profile blood test measures the levels of various hormones, including testosterone, in the blood. Testosterone is the primary male sex hormone responsible for the development and maintenance of male sexual characteristics, as well as playing a role in maintaining overall health. Low testosterone levels can cause symptoms such as decreased libido, erectile dysfunction, fatigue, and mood changes. High testosterone levels may be associated with certain conditions such as polycystic ovary syndrome (in females) or androgen-secreting tumors. The male hormone profile helps evaluate testosterone levels and other hormone imbalances to aid in the diagnosis and management of conditions related to male hormonal health.

IMAGING TEST

• Plain X-Ray — Kidneys, Ureters, and Bladder (KUB): This is a simple and non-invasive imaging test that uses X-rays to visualize the urinary system. It provides information about the size, shape, and position of the kidneys, as well as the presence of urinary stones, calcifications, or other abnormalities. A KUB X-ray is often used as an initial screening tool for conditions such as kidney stones or urinary tract infections. However, it has limitations in detecting smaller or non-calcified abnormalities.
• Intravenous Urogram (IVU): This is also known as an intravenous pyelogram (IVP), it is an imaging test that uses contrast dye injected into a vein to visualize the urinary system. The contrast dye helps highlight the kidneys, ureters, and bladder on X-ray images, allowing for detailed evaluation of the urinary tract. IVU is useful in diagnosing conditions such as kidney stones, urinary tract obstructions, tumors, or structural abnormalities. It provides information about the size, shape, and function of the urinary organs.
• CT Scan (CT IVU): This is known as a computed tomography, is a more advanced imaging technique that uses X-rays and computer technology to create detailed cross-sectional images of the body. A CT IVU specifically focuses on visualizing the urinary tract using intravenous contrast dye. It provides more detailed information compared to a plain X-ray or IVU and is particularly helpful in detecting smaller stones, tumors, or abnormalities in the urinary system. CT IVU can also provide information about other structures, such as the abdomen, pelvis, or lymph nodes, that may be relevant to the diagnosis or staging of urological conditions.
• MRI Scan: Magnetic resonance imaging (MRI) is an imaging test that uses magnetic fields and radio waves to create detailed images of the body. MRI scans provide excellent soft tissue visualization and are useful in evaluating the kidneys, bladder, and surrounding structures. MRI scans can help diagnose and stage urological conditions, such as kidney tumors or prostate cancer. They can also provide information about blood flow, inflammation, or structural abnormalities that may not be well visualized on other imaging modalities. In some cases, a contrast dye may be administered to enhance certain structures or abnormalities during an MRI scan.
• Radioisotope Studies (Renogram, Bone Scan): Radioisotope studies involve the injection of a small amount of a radioactive substance into the bloodstream, which can then be detected by a specialized camera. Renogram is a radioisotope study used to assess kidney function, particularly the filtration and drainage of the kidneys. It provides information about the blood flow and functioning of the kidneys and is commonly used to evaluate conditions such as hydronephrosis, renal artery stenosis, or kidney transplant function. Bone scans, another type of radioisotope study, are used to detect and evaluate bone metastases or other abnormalities in the skeletal system.

SPECIAL UROLOGY TEST

• Uroflowmetry (Urine Flow Test): This is a non-invasive diagnostic test used to assess the flow rate and pattern of urine during voiding. It measures the volume of urine voided over time, providing information about the function of the lower urinary tract, including the bladder and urethra. During uroflowmetry, the patient urinates into a special device that records the flow rate. Uroflowmetry helps evaluate urinary flow obstruction, bladder emptying efficiency, and the presence of conditions such as urinary retention or weak urinary stream. It is a valuable tool in diagnosing and monitoring various urological conditions, including benign prostatic hyperplasia (BPH), urethral strictures, or neurogenic bladder dysfunction.
• Post-void Urine Volume Measurement: This is a simple and non-invasive test that determines the amount of urine remaining in the bladder after urination. It is typically performed using an ultrasound device or a bladder scanner. By measuring the post-void urine volume, healthcare professionals can assess bladder emptying efficiency and identify conditions such as incomplete bladder emptying or urinary retention. Post-void urine volume measurement is often used in conjunction with other diagnostic tests, such as uroflowmetry, to provide a comprehensive evaluation of lower urinary tract function.
• Urodynamics: This is a specialized diagnostic test used to evaluate the function and dynamics of the lower urinary tract, including the bladder and urethra. It provides detailed information about how the urinary system stores and releases urine. Urodynamics involves the measurement of various parameters, such as bladder pressure, urine flow rate, and muscle activity during filling and emptying of the bladder. It can help diagnose conditions such as urinary incontinence, overactive bladder, or bladder outlet obstruction. Urodynamics may include tests such as uroflowmetry, cystometry (measuring bladder pressure), pressure flow study, electromyography (muscle activity measurement), or video urodynamic studies. The results of urodynamic testing guide treatment decisions and help develop personalized management plans for urological conditions.

TELESCOPIC EXAMINATION OF URINARY TRACT

Telescopic examinations like cystoscopy and ureteroscopy play a crucial role in the diagnosis and treatment of various urological conditions. They allow direct visualization of the urinary tract, provide accurate assessments, and enable targeted interventions, ultimately improving patient care and outcomes.

• Cystoscopy (using Flexible and Rigid Instruments): Cystoscopy is a diagnostic procedure in urology that involves the use of a cystoscope, a thin, flexible or rigid instrument with a light and camera at its tip. It allows direct visualization and examination of the inside of the urinary bladder and urethra. During a cystoscopy, the cystoscope is inserted into the urethra and advanced into the bladder. This provides detailed images of the bladder wall, urethra, and other structures in the urinary tract. Cystoscopy can help diagnose various urological conditions, such as bladder stones, bladder tumors, urinary tract infections, urethral strictures, or urinary incontinence. It is also used for therapeutic purposes, such as the removal of small bladder stones or the placement of ureteral stents.
• Flexible cystoscopy is performed using a thin and flexible cystoscope, which allows easier navigation through the curved urethra. It is often performed in an outpatient setting and is generally well-tolerated with minimal discomfort.
• Rigid cystoscopy, on the other hand, uses a stiffer instrument and is typically performed under general or regional anesthesia. It provides a wider field of view and allows for more extensive diagnostic and therapeutic interventions if needed.
• Ureteroscopy (using Flexible or Rigid Instruments): Ureteroscopy is a minimally invasive procedure used to visualize and treat conditions in the upper urinary tract, specifically the ureters and kidneys. It involves the use of a ureteroscope, a thin, flexible or rigid instrument with a light and camera at its tip. The ureteroscope is inserted into the urethra and advanced through the bladder and into the ureter. This allows direct visualization of the ureteral lining, detection of stones, tumors, or other abnormalities, and the ability to perform therapeutic interventions. Ureteroscopy can be used for diagnostic purposes, such as obtaining biopsies or cytology samples, as well as for therapeutic interventions, including the removal of kidney or ureteral stones, treatment of ureteral strictures, or placement of stents to improve urine flow. The choice between flexible and rigid ureteroscopy depends on the specific case and the expertise and preferences of the urologist.
• Flexible ureteroscopy uses a thin and flexible ureteroscope, allowing it to navigate through the twists and turns of the ureter more easily. It is particularly useful for accessing the entire length of the ureter and treating small to moderate-sized stones or other conditions.
• Rigid ureteroscopy, on the other hand, uses a stiffer instrument and is typically employed for larger stones or more complex cases. It may require general or regional anesthesia and is often performed in an operating room setting.

BIOPSY

A prostate biopsy is a procedure performed in urology to obtain tissue samples from the prostate gland for microscopic examination. It is commonly used to diagnose or rule out prostate cancer and to provide information about the aggressiveness and extent of the disease. There are two main approaches to performing a prostate biopsy: finger-guided biopsy and ultrasound-guided biopsy. The choice between finger-guided and ultrasound-guided biopsy depends on the specific clinical situation, the presence of suspicious findings on imaging, and the expertise and preference of the urologist. The procedure aims to provide accurate information about the presence and extent of prostate cancer, allowing for appropriate treatment planning and monitoring.

• Finger-guided biopsy: This is also known as a digital rectal examination (DRE) biopsy, this method involves the urologist inserting a gloved finger into the rectum to feel the prostate gland. By palpating the prostate, the urologist can detect any abnormalities, such as nodules or areas of firmness. If an abnormality is felt, a biopsy needle is then inserted through the rectum to collect small tissue samples from the suspicious areas. This technique is typically used when there is a palpable abnormality on DRE or when prostate cancer is suspected based on elevated prostate-specific antigen (PSA) levels.
• Ultrasound-guided biopsy: This approach utilizes real-time ultrasound imaging to guide the needle placement during the biopsy procedure. A transrectal ultrasound (TRUS) probe is inserted into the rectum to visualize the prostate gland. The urologist can then precisely target specific areas of interest, such as suspicious lesions or abnormal regions identified on imaging (such as MRI). Under ultrasound guidance, a biopsy needle is advanced through the rectum to collect tissue samples from the targeted areas. This technique allows for accurate targeting of suspicious areas and improves the diagnostic yield of the biopsy.

Both finger-guided and ultrasound-guided prostate biopsies are typically performed as outpatient procedures. Local anesthesia is administered to numb the area, and the biopsy needle is inserted through the rectum into the prostate gland. Multiple tissue samples, usually 12 or more, are obtained from different areas of the prostate. After the procedure, patients may experience temporary discomfort, mild bleeding in the urine or semen, and may need to take antibiotics to prevent infection.

The collected prostate tissue samples are sent to a pathology laboratory for microscopic examination by a pathologist. The pathologist analyzes the tissue samples to determine if there are cancerous cells present, the grade of the cancer (Gleason score), and other characteristics that help guide further management decisions.

EXAMINATION & MANAGEMENT PRACTICES OF UROLOGY PATIENTS

• Patient History Taking
• Physical Examination
• Investigation
• Diagnosis (Clinical Impression)
• Differential Diagnosis
• Treatment
• Complication of Treatment and their management

PATIENT HISTORY TAKING

When taking the patient’s history in urology, it is important to gather relevant information related to the urinary system and associated symptoms. This includes details about urinary complaints such as frequency, urgency, hesitancy, incontinence, pain or discomfort during urination, blood in urine (hematuria), and any changes in urinary patterns. Additionally, obtaining a comprehensive medical history, including past surgeries, medications, family history of urological conditions, and any relevant social or occupational factors, can provide valuable insights. The patient’s sexual history and reproductive health should also be addressed, especially when evaluating conditions such as erectile dysfunction or infertility.

PHYSICAL EXAMINATION

A thorough physical examination is conducted to evaluate the patient’s urological health. It typically includes inspection, palpation, percussion, and auscultation. The examination may focus on the abdomen, pelvis, groin, genitalia, and rectum. Specific areas of examination may include the kidneys, bladder, prostate (in males), urethra, and lymph nodes. For males, a digital rectal examination (DRE) may be performed to assess the prostate gland. In females, a pelvic examination may be necessary to evaluate the pelvic organs. Physical examination helps identify any abnormalities, such as masses, tenderness, enlarged organs, or hernias, which aid in formulating a diagnosis and treatment plan.

INVESTIGATIONS:

Urological investigations are employed to aid in diagnosis and guide treatment decisions. These investigations may include laboratory tests, imaging studies, and specialized procedures. Common laboratory tests in urology include urinalysis, urine culture, blood tests (e.g., renal function tests, prostate-specific antigen), and hormonal assays (in cases of hormone-related conditions). Imaging studies such as ultrasound, CT scan, MRI, or nuclear medicine scans are used to visualize the urinary tract and identify structural abnormalities, stones, tumors, or infections. Specialized procedures, such as cystoscopy or urodynamic studies, may be performed to assess the bladder, urethra, or ureters.

DIAGNOSIS (CLINICAL IMPRESSION)

Based on the patient’s history, physical examination findings, and investigation results, the urologist forms a clinical impression or diagnosis. This involves analyzing the collected information and correlating it with known urological conditions. The diagnosis may be a specific condition or a provisional diagnosis that requires further investigation or confirmation. The clinical impression serves as a basis for developing an appropriate treatment plan.

DIFFERENTIAL DIAGNOSIS

In urology, it is crucial to consider a wide range of potential diagnoses during the differential diagnosis process. This involves systematically considering and evaluating various conditions that could explain the patient’s symptoms and presentation. The differential diagnosis helps the urologist rule out certain conditions and narrow down the possibilities to the most likely diagnoses. It may involve comparing clinical features, considering risk factors, and utilizing diagnostic tests to differentiate between similar conditions.

TREATMENT

The treatment plan for urology patients depends on the specific diagnosis and individual patient factors. It may involve non-surgical interventions such as medication, lifestyle modifications, or conservative management. In some cases, surgical interventions may be necessary, ranging from minimally invasive procedures to major surgeries. Treatment options in urology encompass a broad range of conditions, including urinary tract infections, kidney stones, benign prostatic hyperplasia (BPH), prostate cancer, bladder cancer, urinary incontinence, erectile dysfunction, and infertility, among others.

COMPLICATIONS OF TREATMENT AND THEIR MANAGEMENT:

Like any medical intervention, urological treatments can carry potential risks and complications. These can vary depending on the specific treatment modality and the patient’s individual characteristics. Complications may include infection, bleeding, injury to surrounding structures, pain, adverse reactions to medications, or treatment failure. Urologists are well-prepared to manage and address complications that may arise during or after treatment. The management of complications often involves a multidisciplinary approach, with collaboration between urologists, nurses, radiologists, and other healthcare professionals.

Some common complications and their management in urology include:

• Infection: Antibiotics are commonly prescribed to treat and prevent infection. In cases of severe infection, hospitalization and intravenous antibiotics may be required. Proper sterile techniques during procedures and postoperative care can help minimize the risk of infection.
• Bleeding: Bleeding can occur during surgical procedures or as a result of trauma to the urinary tract. Depending on the severity, interventions may include cauterization, compression, or blood transfusions. In some cases, surgical exploration or embolization may be necessary to control bleeding.
• Pain: Adequate pain management is crucial for patient comfort. Pain medications, both oral and intravenous, are often prescribed. In some cases, regional anesthesia techniques may be employed for targeted pain relief. Non-pharmacological approaches such as hot/cold therapy or relaxation techniques may also be utilized.
• Treatment failure: In some instances, the initial treatment may not achieve the desired outcome. If treatment fails to alleviate symptoms or resolve the underlying condition, alternative treatment options may be considered. This may involve re-evaluating the diagnosis, performing additional investigations, or exploring different therapeutic approaches.
• Adverse reactions to medications: Some patients may experience adverse reactions to medications used in urological treatments. These can include allergic reactions, gastrointestinal upset, or other side effects. Managing adverse reactions may involve adjusting the medication dosage, switching to an alternative medication, or providing supportive care to alleviate the symptoms.
• Psychological and emotional complications: Urological conditions and treatments can have a significant impact on a patient’s psychological well-being. Urologists may collaborate with mental health professionals to provide counseling and support for patients dealing with anxiety, depression, or other emotional challenges related to their condition or treatment.

It is important for urologists to educate patients about the potential complications associated with treatment and to provide appropriate follow-up care to monitor for any signs of complications. Prompt recognition and management of complications can lead to improved patient outcomes and overall satisfaction with urological care.

PRE-AND POST-OPERATIVE CARE OF UROLOGY PATIENTS — (ISSUES OF PATIENT SAFETY AND CONSENT)

PRE-OPERATIVE CARE:

• Patient Safety: Prior to any urological surgery, patient safety is of paramount importance. This includes ensuring that the patient is in optimal medical condition for the procedure. Pre-operative assessments are conducted to evaluate the patient’s overall health, identify any underlying medical conditions, and assess their fitness for surgery. This may involve laboratory tests, imaging studies, and consultations with other specialists as necessary.
• Informed Consent: Obtaining informed consent is a crucial ethical and legal requirement. Urologists must explain the nature of the proposed surgery, potential risks and benefits, alternatives, expected outcomes, and the post-operative recovery process to the patient. The patient should have a clear understanding of the procedure and its implications before providing their consent. Written consent is typically obtained, and the patient is given an opportunity to ask questions or seek additional information.
• Pre-operative Instructions: Patients receive detailed instructions regarding pre-operative preparations. These instructions may include guidelines on fasting (avoiding food and liquids for a specific period before surgery), discontinuing certain medications, and adhering to specific hygiene practices (e.g., cleansing with antiseptic solutions). It is essential for patients to follow these instructions to minimize the risk of complications and ensure a successful surgical outcome.
• Anesthesia Evaluation: If general anesthesia or regional anesthesia is required, patients may undergo a pre-operative anesthesia evaluation. An anesthesiologist assesses the patient’s fitness for anesthesia, discusses the anesthesia plan, and addresses any concerns or questions the patient may have.

POST-OPERATIVE CARE:

• Recovery and Monitoring: Following urological surgery, patients are monitored closely during the post-operative period. Vital signs such as heart rate, blood pressure, and oxygen saturation are monitored, and pain levels are assessed. Post-operative recovery and monitoring take place in a designated recovery area or hospital room. The patient’s comfort, pain management, and overall well-being are prioritized.
• Wound Care and Infection Prevention: Proper wound care is essential to prevent infection and promote healing. Urologists and nurses provide instructions on wound care techniques, including dressing changes, keeping the area clean and dry, and monitoring for signs of infection such as increased pain, redness, swelling, or discharge. Patients may be prescribed antibiotics to prevent or treat infections.
• Pain Management: Effective pain management is crucial for patient comfort and recovery. Pain medications are administered as prescribed, and different methods of pain control, such as oral medications, patient-controlled analgesia (PCA), or epidural anesthesia, may be utilized depending on the nature of the surgery and the patient’s condition. Regular pain assessments are conducted, and adjustments to the pain management plan are made as needed.
• Mobilization and Rehabilitation: Early mobilization and rehabilitation are encouraged to minimize the risk of complications and promote faster recovery. Patients may receive guidance from physical therapists or nurses on safe movements, ambulation, and exercises that can be done post-surgery. This helps restore mobility, prevent blood clots, and enhance overall recovery.
• Follow-up Care and Discharge Planning: Urologists provide specific instructions regarding post-operative care, including medication regimens, dietary guidelines, activity restrictions, and follow-up appointments. Patients and caregivers are educated about potential signs of complications and advised on when to seek medical attention. Discharge planning includes coordinating any necessary home care services, arranging follow-up appointments, and providing appropriate resources and educational materials for patients’ self-care at home.

Throughout the pre- and post-operative care process, urologists work in collaboration with a multidisciplinary team, including nurses, anesthesiologists, and other healthcare professionals, to ensure patient safety, optimize outcomes, and provide comprehensive care.

QUESTIONS FOR REFLECTION & FURTHER STUDY

• What is Urology?
• List some common urological conditions
• List common symptoms of urological conditions
• List common investigations in Urology
• Write short notes on common urological conditions
• Describe the aetiology, clinical presentation, diagnosis and management of at least two common urological conditions

USEFUL TIPS

• Attend urology ward rounds
• Attend urology clinics
• Clerk and present cases
• Attend urology procedure room to observe uroflowmetry, bladder scan and prostate biopsy
• Attend urology theatre to observe common urological procedures
• Attend revision sessions close to the examination