ABC OF UROLOGY Second Edition ChapFM.qxd 6/7/06 9:19 PM Page i ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield © 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5 ABC OF UROLOGY Second Edition Edited by Chris Dawson Consultant Urological Surgeon, Edith Cavell Hospital, Peterborough Hugh N Whitfield Consultant Urological Surgeon, Harold Hopkins Department of Urology, Royal Berkshire Hospital, Reading Blackwell Publishing ChapFM.qxd 6/7/06 9:19 PM Page iii © Blackwell Publishing Ltd 2006 BMJ Books is an imprint of the BMJ Publishing Group, used under licence Blackwell Publishing Inc., 350 Main Street, Malden, Massachusetts 02148–5020, USA Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia The right of the Author to be identified as the Author of the Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior written permission of the publisher. First published 1997 Second edition 2006 1 2006 Library of Congress Cataloging-in-Publication Data ABC of urology / edited by Chris Dawson, Hugh N. Whitfield. — 2nd ed. p. ; cm. “BMJ Books.” Includes bibliographical references and index. ISBN-13: 978-1-4051-3959-5 ISBN-10: 1-4051-3959-5 1. Urology. 2. Genitourinary organs — Diseases. I. Dawson, Chris, MBBS. II. Whitfield, Hugh N. [DNLM: 1. Urologic Diseases — diagnosis. 2. Urologic Diseases — therapy. 3. Genital Diseases, Male — diagnosis. 4. Genital Diseases, Male — WJ 140 A134 2006] RC871.A13 2006 616.6—dc22 2006012216 ISBN-13: 978-1-4051-3959-5 ISBN-10: 1-4051-3959-5 A catalogue record for this book is available from the British Library Cover image of a urinary tract x-ray is courtesy of Sovereign, ISM/Science Photo Library Set in 9/11 pts New Baskerville by Newgen Imaging System Pvt., Ltd, Chennai, India Printed and bound in Singapore by C.O.S. Printers Pte Ltd Commissioning Editor: Eleanor Lines Editorial Assistant: Vicky Pittman Development Editor: Sally Carter / Vicki Donald Production Controller: Debbie Wyer For further information on Blackwell Publishing, visit our website: www.blackwellpublishing.com The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has been manufactured from pulp processed using acid-free and elementary chlorine-free practices. Furthermore, the publisher ensures that the text paper and cover board used have met acceptable environmental accreditation standards. Blackwell Publishing makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check that any product mentioned in this publication is used in accordance with the prescribing information prepared by the manufacturers. The author and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this book. ChapFM.qxd 6/7/06 9:19 PM Page iv Contents Contributors vi Preface vii Introduction to urology ix 1 Urological evaluation 1 Hugh N Whitfield 2 Bladder outflow obstruction 6 Jyoti Shah 3 Urinary incontinence 10 Helen Zafirakis-Hegarty 4 Urological emergencies 14 Adam Jones 5 Subfertility and male sexual dysfunction 18 Stephanie Symons 6 Management of urinary tract infection in adults 22 Philippa Cheatham 7 Prostate cancer 25 Chris Dawson 8 Bladder cancer 29 Derek Fawcett 9 Renal and testis cancer 34 Paul K Hegarty 10 Urinary tract stone disease 37 Hugh N Whitfield 11 Common paediatric problems 40 A R Prem 12 Genitourinary trauma 44 Asif Muneer Index 49 v ChapFM.qxd 6/7/06 9:19 PM Page v Philippa Cheatham Specialist Registrar in Urology, Harold Hopkins Department of Urology, Royal Berkshire Hospital, Reading Chris Dawson Consultant Urological Surgeon, Edith Cavell Hospital, Peterborough Derek Fawcett Consultant Urological Surgeon, Harold Hopkins Department of Urology, Royal Berkshire Hospital, Reading Paul K Hegarty Specialist Registrar Urology, Great Ormond Street Hospital, London Adam Jones Consultant Urological Surgeon, Harold Hopkins Department of Urology, Royal Berkshire Hospital, Reading Asif Muneer Specialist Registrar in Urology, Harold Hopkins Department of Urology, Royal Berkshire Hospital, Reading A R Prem Senior Registrar in Urology, The Armed Forces Hospital, Al- Khoud, Sultanate of Oman Jyoti Shah Specialist Registrar in Urology, Northwick Park Hospital, Harrow Stephanie Symons Specialist Registrar in Urology, Edith Cavell Hospital, Peterborough Hugh N Whitfield Consultant Urological Surgeon, Harold Hopkins Department of Urology, Royal Berkshire Hospital, Reading Helen Zafirakis-Hegarty Specialist Registrar in Urology, Edith Cavell Hospital, Peterborough Contributors ChapFM.qxd 6/7/06 9:19 PM Page vi vii Preface There have been considerable technical and scientific innovations since the publication of the first edition of the ABC of Urology nearly 10 years ago. The time is therefore right for the publication of this revised second edition. Acknowledging the progress made in each area of urology we felt that it was appropriate for us to take on an editorial role and invite specialist authors each to contribute to their area of expertise. Each chapter has been completely rewritten and contains up to date information contributed by an expert in the field. We hope that this edition will be the more authoritative as a result. The ABC of Urology remains a useful introduction to the subject for surgeons training for the MRCS and will also provide a source of information for medical students. The style of each chapter also means that this book will prove a useful resource for nursing and ancillary staff dealing with patients with urological problems. We remain indebted to the staff of Blackwell Publishing without whose efforts this revised edition would not have been possible. Chris Dawson and Hugh N Whitfield ChapFM.qxd 6/7/06 9:19 PM Page vii Urological disorders account for about one third of all surgical admissions to hospital. Urological pathology is also a common reason for patients to present in primary care. Although few urological conditions are immediately life threatening, many may have a profound effect on the patient’s quality of life. As with all other medical and surgical specialties, subspecialisation has occurred within urological practice. Evidence in the confidential enquiry into perioperative deaths (CEPOD) highlighted that transurethral prostatectomy, the operation performed most often in urological departments, is associated with a significantly lower mortality when performed by surgeons who undertake more than 50 such procedures a year. Most urologists will undertake core urology and will subspecialise in one or two of the component parts of urology. One common theme is that urological surgery requires specialised urological nursing to be effective Urodynamic disorders Problems of bladder outflow obstruction secondary to benign prostatic hypertrophy constitute about one third of cases in urological practice. Other urodynamic disorders occur in patients with neurological disorders of many kinds. The management of patients with urinary incontinence may also be included under this heading, although urogynaecologists are now taking over a considerable part of this workload. Oncology Prostate and bladder cancer are the two most common malignant diseases that present to urologists. The numbers of renal and testicular cancers that are being found seems to be increasing. All patients with malignant diseases now come under the care of a multidisciplinary team that consists of urologists, oncologists, radiologists, and histopathologists. Urological oncologist nurses have an increasing role to play in the counselling and follow-up of patients with malignant disease. Stone disease In most urological departments with five or more urologists, one urologist will have a subspecialty interest in stone disease. The need for expensive technology dictates that the most comprehensive care for patients with stone disease can be provided only in centres with an onsite lithotripter and equipment for endoscopic treatments, including lasers. Such a capital investment can be justified only for a population base of 750 000–1 000 000. Reconstruction Paediatric urologists are responsible for managing congenital anomalies that need urological reconstruction. In adult practice, urethral stricture disease remains a challenge. After radical cystectomy for bladder cancer, some patients with incontinence can be offered a reconstructive procedure that may be performed by an oncological or reconstructive surgeon. A few ix Introduction to urology Hugh N Whitfield Subspecialties in urology G Urodynamics G Oncology G Stone disease G Reconstruction G Paediatric urology G Andrology A robotic laparoscopy system A lithotripter ChapFM.qxd 6/7/06 9:19 PM Page ix patients with intractable urological incontinence may also be offered a reconstructive procedure. Uncommon problems involving the ureters also may require a reconstructive procedure, with the small intestine used to substitute for the ureter. Paediatric urology Paediatric urological disorders are managed best by those with special expertise in the investigation, surgery, and nursing of children. The regulations that surround the care of children are creating a situation in which it is increasingly difficult for an adult urologist to undertake any paediatric urology. This is not always appropriate, as the small number of paediatric urologists, at least in the United Kingdom, should be devoting their time to problems more complex than phimosis and undescended testicle, which can be managed very well by non-specialists. Andrology The role of the urologist in the management of erectile dysfunction and subfertility is changing. With the advent of oral agents to treat most patients with erectile dysfunction, much of this component of urology has been taken on by primary care doctors. Urologists who subspecialise in andrology may be more involved in the surgery of patients with severe Peyronie’s disease and those who request gender reassignment. Renal transplantation In most centres, dedicated transplant surgeons are responsible for renal transplantation. Urologists become involved only in cases in which patients have postoperative ureteric problems or renal stone disease. Changes in urological practice In the last 10 years many changes have resulted in a considerable shift in the scope of urological care. More effective medical treatment for benign prostatic hyperplasia has resulted in a reduction in the number of operations required for this common problem. As mentioned above, specialists from other disciplines are playing an increasing role in the management of andrological disorders and of urodynamic disorders in women. Laparoscopic surgery is performed increasingly within urology. The dilemma arises to decide whether laparoscopic surgeons will remain organ and pathology based or technique based. As the requirement for urological specialists to perform surgery is diminishing, the training of urologists must adapt to accommodate these changes. Just starting in the United Kingdom is a two stage system; a three year training in core urology to produce a “consultant urologist” will start after basic surgical training. The scope of the surgery that consultant urologists undertake will be limited. Those who wish to become urological surgeons will have to hope that manpower calculations show a need before they undertake a further period of training for two or three years in a urological surgical subspecialty. Currently, the United Kingdom has a lower ratio of urologists per head of the population than any other developed country. Introduction to urology x Male factor infertility G Some centres have a combined clinic, in which a gynaecologist and urologist see both partners at the same time G Gynaecologists are now undertaking much of the care of men with subfertility, although surgery for vasal blockage and varicocoele remain the remit of urologists Ratio of urologists to population Country Ratio Luxembourg 1:27 000 United States 1:29 000 Czech Republic 1:29 000 Spain 1:35 000 Portugal 1:40 000 Belgium 1:40 000 Netherlands 1:56 000 United Kingdom 1:100 000 Balanitis and phimosis in a 5 year old boy. Reproduced with permission from Dr P Marazzi/Science Photo Library ChapFM.qxd 6/7/06 9:19 PM Page x Philosophy of urology The investigation and treatment of patients with urological disorders tends to be minimally invasive. The urological equivalent of diagnostic laparotomy seldom, if ever, is needed. Most of even the most major urological surgical procedures may be performed laparoscopically. This will become the standard in the next few years. The pharmaceutical industry is anticipating an increase in the proportion of medically treated urological disorders: from 5% to 15% over the next 10 years. With an ageing population and increased expectation for quality of life, the demand for medical and surgical urological care is likely to increase. Manpower predictions for training purposes will become increasingly complex. Shared care between urologists and primary care doctors is common and effective. Integration with other healthcare professionals—such as district nurses, physiotherapists, radiographers, and urology nurse practitioners based in hospitals—also has a pivotal role. One recent example of close collaboration is the setting up of multidisciplinary tumour group meetings to manage patients with urological cancers. The provision of urological health is likely to shift in the next few years. The role of the “independent sector” in the provision of non-oncological urology is unclear, and the latter may become the “Cinderella” of the specialty. Urologists have a reputation for innovation. Although innovations can be of great benefit to patients—for example, extracorporeal shock wave lithotripsy—the recent history of urology is littered with examples of technologies that have been introduced with great enthusiasm by their protagonists but abandoned after a short time. The advent of a scrutinising committee from the National Institute for Clinical Excellence should act to hold back those who are overenthusiastic. Introduction to urology xi Participants in shared care G Urological surgeon G General practitioner G District nurses G Continence nurses G Stoma therapists Participants in multidisciplinary teams G Urological surgeons G Oncologists G Radiotherapists G Histopathologists G Radiologists G Nurse oncologists Urological provision is changing G More care based in community G Emergency care provided by emergency departments of district general hospitals G Elective surgery for oncology available at centres that provide care for populations of about 1 million people ChapFM.qxd 6/7/06 9:19 PM Page xi 1 Urological complaints The most common urological complaints that trigger the need for referral to a primary care doctor or urological surgeon can be divided into those referable to the lower urinary tract and those referable to the upper urinary tract. Although a careful history may be diagnostic in patients with, for example, renal colic or testicular torsion, very often non-specific features are more difficult to unravel. Symptoms The bladder has been described as an unreliable witness. Sensory innervation is mediated largely through parasymapathetic nerves, with pain from overdistension mediated through the sympathetic nervous system. The precision with which the site and cause of symptoms in the lower and upper urinary tracts can be identified from this autonomic innervation is limited. Similar symptoms may occur as the result of different pathology. The art of urological evaluation on the basis of symptoms depends on understanding how much reliance can be placed on the patient’s account of different symptoms and symptom complexes. This also depends on the ability of the doctor to phrase questions so that the patient is clear about their meaning. Obstructive symptoms Hesitancy of micturition can be a reliable symptom. The patient can quantify accurately a delay in initiation of the urinary stream. Using quite crude analogies, most men can describe whether their urinary stream is fast or slow—that is, strong or weak. A man’s ability to write his initials with his urine on the wall behind a urinal indicates a strong stream, whereas a stream that dribbles onto his toes obviously is weak. Patients can confirm if their urinary stream is intermittent, and this is a good indicator of obstruction. A feeling of incomplete bladder emptying correlates poorly with objective findings on ultrasound. Irritative symptoms A burning sensation on micturition is common in patients with a lower urinary tract infection. A similar sensation can occur in the absence of infection, however, and infection can occur in the absence of any discomfort. The term “dysuria” is often applied to a burning sensation on micturition, but it means different things to different people and is best avoided. Urgency of micturition may be sensory or motor in origin, but when a history is taken, it is hard to distinguish between the two—although the underlying pathologies are very different. Patients with urgency feel as if they may leak urine if they are not able to reach a lavatory imminently. The sensation of needing to pass urine again just after micturition—strangury— is the urological equivalent of tenesmus. In the urinary tract, the symptom is not diagnostic for any one pathology. Frequency of micturition When patients are asked to describe their urinary frequency, they have every opportunity for an unhelpful and lengthy reply. The number of times a patient wakes to pass urine at night is a value that most people can identify accurately. A single episode 1 Urological evaluation Hugh N Whitfield Differentiation between urological and non-urological causes of non-specific symptoms can be made only after basic urological investigation Urological symptoms G Obstructive symptoms G Irritative symptoms G Erectile dysfunction and sexual problems G Urinary incontinence G Pain G Renal colic G Fever G Haematuria Obstructive symptoms G Hesitancy G Poor stream G Intermittent stream G Terminal dribbling Irritative symptoms G Burning on micturition G Urgency G Daytime frequency G Nocturia G Urge incontinence Input/Output Chart Name......................................... Input Time Volume and type of fluid Time Volume Output Date......................................... Recording frequency of micturition on a “time and volume” chart can be useful Chap01.qxd 6/7/06 9:06 PM Page 1 ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield © 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5