AUSTIN UROLOGY A centre for excellence in urological surgery

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What is urology?

UROLOGY
deals with medical problems arising from the genitourinary system.

This system (see pictures below) is made up of the
kidneys, adrenal glands, ureters, urinary bladder, urethra and in the male the prostate gland, penis and testicles.

We can categorise most conditions depending on which organ or which part of the urinary system they involve.

Male Urinary Tract

Female Urinary Tract

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The Kidney

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The kidney is a paired organ so normally there is one left kidney and one right kidney and they are located around the middle-back region just either side of the spine. They lie front of the lowest 11th and 12th ribs and on the deep portion of the loins behind the abdominal cavity and its contents (stomach, gut, liver, gallbladder and pancreas).

What does the kidney do?

  • Produces urine (waste products from the bloodstream)

  • Regulate blood pressure and 'electrolytes' (e.g. salt molecules)

  • Produce hormones (including those that stimulate red blood cells and regulators of calcium and water absorption)

What conditions are associated with the kidney?

Kidney Stones (also called Renal Stones, Renal Lithiasis or Renal Calculi) are hard, insoluble deposits that form in the urine collecting system of the kidney and can affect any part of the urinary tract. The two most important factors about kidney stones are their size and position in the urinary system. Small stones will pass spontaneously with minimal or no symptoms. If a stone is too big then it will get stuck and therefore can cause pain (medically known as renal colic) which occurs in the flank and groin. Other symptoms include nausea, vomiting, pain on urination, frequency of urination and sometimes symptoms of infection (e.g. fever and chills).

Treatment of kidney stones depends on the type of stone, its location, previous kidney function and whether an infection is present. Stones which
block a kidney (from lodging of a stone in the ureter) and especially those with underlying infection need urgent medical attention and are often treated with a stent (plastic tube) placed via the skin (nephrostomy) or a stent placement via the urethra and bladder from below whilst asleep (general anaesthetic). Stones which do no require urgent attention can be treated with medical dissolving therapy if appropriate, lithotripsy (a machine outside the body which sends shockwaves and fragments the stone), uretersocopy (a small camera passed up the ureter and stone is seen and fragmented directly) or more uncommonly percutaneous nephrolithotomy PCNL (a small incision in the flank direct to the kidney).


Kidney masses are growths found on ultrasound and CT X-ray pictures which look abnormal compared to normal kidney tissue. Often these are found by accident (incidentally) during routine tests for other conditions. Around 10-15% of renal masses are benign (non-cancerous) but some may still require treatment. If a mass looks suspicious for cancer (malignant) then it is often removed surgically or destroyed by other methods radiologically. Often the final diagnosis of what the mass actually is, is made after surgery. If a mass is small then a urologist will perform a partial nephrectomy (removing only the mass and a narrow ring of normal tissue) thereby preserving as much kidney function as possible. Otherwise if the tumour is big then a radical nephrectomy (removal of the whole kidney) will be performed.


The Adrenal Glands

What are the adrenal glands?

There are two adrenal glands and they sit right on top of the each kidney (like a hat). They are glands which release hormones which have various effects on the body.

What hormones are released by the adrenals and what does each one do?

  • Cortisol = released a times of stress and low blood sugar

  • Aldosterone = helps regulate blood pressure by acting on the kidney so water and salts are reabsorbed rather than excreted

  • Adrenalin (epinephrine) = the fight-or-flight hormone which increases heart rate and breathing, increases energy (glycogenolysis) and redistributes blood flow away from the internal organs and to the limbs. Adrenalin also has many medical uses.

  • Noradrenalin = very similar effects to Adrenalin, and underlies the fight-or-flight response

  • Androgens = broadly refers to sex hormones such as testosterone. Although in males the adrenals only produce around 5% of testosterone and the majority is produced is the testes

What conditions are associated with the adrenal glands?

  • Addison's disease = under-activity of the outer-rim of the adrenal glands. Reduced hormones: aldosterone, cortisol and sex hormones

  • Cushing's syndrome = excessive cortisol ('stress') hormone.

  • Phaeochromocytoma = a rare condition with excessive production of adrenalin and noradrenalin, which is produced in the middle of the adrenal gland.

  • Adrenal adenoma = benign growth in the adrenal which may cause excessive hormone production (e.g. Cushing's syndrome - see above). This may need removal of the affected adrenal gland by adrenalectomy (removal of the adrenal gland).

  • Adrenal carcinoma = this is a malignant growth in the adrenal gland. Treatment of choice for these growths is by adrenalectomy

The Ureters

What are the ureters?

The ureters are hollow muscular tubes that connect each kidney with the bladder. They are around 25cm in length and have muscle fibres in their walls to squeeze urine down towards the bladder.

What conditions are associated with the ureters?

Stones
- causing pain and/or blocking urine from kidney to bladder. Stones are normally formed in the kidney and 'drop' into the ureter. If the stone is too big it may get stuck and will need surgery to be removed.

Stricture
- a narrowing in the hollow part of the ureter, most commonly caused by scarring. Sometimes this is from outside the ureter by a nearby structure i.e. the colon, pressing on the ureter. This also may affect urine drainage.

Swelling - growths of cells in the wall of the ureter may impact on it's function. Some growths can be malignant so will need investigation and often surgery.

The Bladder and Urethra

What is the urinary bladder?

The bladder is a hollow, muscular organ that acts as a reservoir for storing urine before urination. Urine enters the bladder via thee ureters and exits via the urethra.
What conditions are associated with the bladder?


  • Bladder cancer is a malignant growth of the inner bladder lining (mucosa). The most common and important symptom of bladder cancer is visible blood in the urine (macroscopic haematuria). Other symptoms can include pain on urination (dysuria), frequency of urination, incomplete bladder emptying, lower abdominal pain and weight loss. The diagnosis of bladder cancer is often visual via a flexible cystoscopy, but often a trans-urethral resection of bladder tumour TURBT (camera into the bladder and tissue cut away) is needed to diagnosis and/or treat the cancer. If the cancer is deep into the muscle of the bladder (detrusor muscle) then often the bladder needs to be removed surgically (cystectomy) and the ureters rejoined into a new bladder (neobladder) or using some bowel as a conduit (ileal conduit).


  • Bladder stones are similar to renal stones but they are formed and/or collect in the bladder causing irritative symptoms on urination. Like renal stones these can be treated with a camera and fragmentation of the stones (cystolithopaxy).


  • Incontinence ('involuntary leakage of urine') - related to overactive bladder muscles or pelvic floor muscle weakness, or a combination of both.


  • Cystitis - this is an irritation of the lining inside the bladder, often associated with urinary tract infection (UTI), treatment such as radiotherapy or recent invasive tests for example cystoscopy.




What is the urethra?

The urethra is the hollow tube from the bladder to the urethral orifice on the outside skin surface. The urethra is longer men compared to women who have a short urethra. The start of the male urethra is surrounded by the prostate gland. In both sexes the urethra allows urine to be excreted from the bladder. Muscle that circle the urethra help hold urine in the bladder and relax when we want to urinate. These are called the internal and external urinary sphincters.

The Prostate Gland

What is the prostate gland?

The prostate is a gland about the size of a walnut and surrounds the first part of the male urethra. It is an important part of the male reproductive system.

What does the prostate gland do?

It produces lubricating fluid for
sperm which makes up around a 1/3 rd of semen volume. During ejaculation muscle fibres within the prostate gland contract the ducts thereby helping with eject semen from the internal tubes, along the urethra and towards the penis.

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What conditions are associated with the prostate?

  • Benign Prostatic Hyperplasia (BPH) - in this condition there is an increased number of prostate cells causing a general enlargement of the gland. During urination large prostate gland can obstruct urine draining from the bladder through the urethra, causing a variety of symptoms.


  • Prostate Cancer - this is a relatively common cancer in men which is often detected in the later stages of life. Although it can affect males as young as 40 years or younger. It can cause urinary symptoms, similar to BPH (see above), but can often be asymptomatic (no symptoms). A raised blood test marker called prostate specific antigen (PSA) is suggestive of prostate cancer, although can be raised in other conditions.


  • Prostatitis - inflammation of the prostate gland, commonly associated with a urinary tract infection (UTI) or invasive tests such as trans-rectal ultrasound (TRUS) biopsy.

The Testes and Male Reproductive Organs

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What are the testes?

The
testes (or testicles) are paired male reproductive organs that produce and store sperm. They are also the main source of the sex hormone: testosterone which stimulates sperm production and is associated with male development during puberty.

Normally the testicles are located in the scrotum, which is a 'sack' made up of skin, muscle and connective tissue. The testicles are suspended outside the body in the scrotum because to produce sperm they have to be just below normal body temperature.


What abnormalities can occur in the testes?

  • Testicular Torsion is a twisting of the testicle in the scrotal sac which blocks off its bloody supply. It often causes sudden onset severe testicular pain on one side. This is a urological emergency and emergency medical attention is required. It often occurs around the adolescent years but is not exclusive to these ages, so if in doubt please seek urgent medical attention.

  • Hydrocele is a collection of fluid around the testicle, often painless and just causing swelling and discomfort. This is diagnosed on ultrasound and can be treated surgically (hydrocele repair).

  • Testicular masses are often discovered via the patient (self-examination) or on a scan (ultrasound). The most consideration is the possibility of testicular cancer which is often a treatable disease if caught early. Diagnosis and treatment achieved by removing the testicle via a cut in the groin (radical inguinal orchidectomy), and sometimes an artificial testicle is inserted if required (prosthesis). If the cancer has spread then further surgery may be required to removed affected lymph nodes such as a sentinal node biopsy or a retroperitoneal lymph node dissection RPLND whereby the nodes surround the large vessels in the abdomen are removed via a cut at the front of the abdomen. Most patients with testicular cancer will receive a course of chemotherapy supervised by the medical oncology team.


How is the structure of the penis important to its function?

The
penis is part of the male reproductive system and contains the final portion of the urethra. It is made up of 3 hollows tubes, one of which on the underside of the penis, contains the penile urethra. During an erection these tubes become engorged with blood causing the penis to become firm.
What medical conditions can affect the penis?


  • Erectile dysfunction (ED) (also known as impotence) is the inability to sustain an erection sufficient for sexual intercourse. There are many causes including: inflammation, mechanical, vascular, trauma/injury, psychological and medication related. The treatment for ED is largely related to the underlying cause. Some advanced treatment options include medical tablets, penile injections or pump devices or insertion of penile prosthesis.

  • Hypospadias - this is a abnormal location of the urethral opening usually found at or shortly after birth

  • Peyrionie's disease - abnormal curvature of the penis, usually cause by scarring.

  • Penile cancer is a rare cancer. Risk factors for developing penile cancer include: human papilloma virus (HPV), smoking, phimosis (tight restrictive foreskin) and inflammation.

All content written by Dr David Wetherell (MBCHB) and reviewed by specialist surgeons Professor Damien Bolton and Associate Professor Nathan Lawrentschuk.
Last Updated 23/10/2014

References:
John Reynard, Simon Brewster, Suzanne Biers. Oxford Handbook of Urology 2009. Oxford University Press: Oxford. 783 ISBN: 9780199534944.

Campbell-Walsh Urology Tenth Edition . Alan J. Wein, Louis R. Kavoussi, Andrew C. Novick, Alan W. Partin and Craig A. Peters . Saunders , 2011 ; 10th revised edition, hardback , 4320 pages ; ISBN-10 : 1416069119 , ISBN-13 : 978-1416069119


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