UNIT 2 CROLOGICAL DISORDERS Structure 2.0 Objectives 2.1 Introduction 22 Urinary Tract Infections 2.2.1 Pathogenesis of Urinary Tract Infections 2.2.2 Diagnosis of UTI 2.2.3 Management 2.2.4 Recurrent Urinary Tract Infection 2.3 Renal Failure 2.3.1 Aetiology of Acute Renal Failure 2.3.2'. Approach to Patient of Acute Renal Failure 2.3.3 Management of Acute Renal Failure 2.3.4 Chronic Renal Failure (CRF) 2.4 Diseases of the 2.4.1 Benign Hypertrophy of Prostate (BPH) 2.4.2 Prostatitis 2.4.3 Prostatic Abscess 2.4.4 Cancer of the Prostate 2.5 Let Us Sum Up 2.6 Key Words 2.7 Answers to Check Your Progress 2.8 Further Reading.

OBJECTIVES

After reading this unit, you should be able to:

I diagnose and manage urinary tract infections; diagnose acute and chronic renal failure and outline principles of management; and identlfy various prostatic problem and offer appropriate .

1I 2.1 INTRODUCTION I In this unit, you will be reading about acute urinary tract infection, which is a problem commonly faced by the elderly. Besides, acute and chronic renal failure, diseases of the prostate, the section acute urinary tract infection deals with collection of urine sample for tests, and the i tests that are commonly performed on the sample, various drugs used for the treatment and I how long the treatment should continue. It also deals with complicated and recurrent urinary tract infection. You will be reading about urinary incontinenence in elderly women, a major problem in the following Unit 3. The next section deals with renal failure both acute and chronic. Acute renal failure can be prevented or reversed if timelyhelp in many cases are available. You will be learning about chronic renal failure, how to manage them, when to refer them and also to decide who are fit for renal transplant. Diseases ofprostate cause mainly urinary problems besides other prostate hypertrophy and carcinoma of the prostate are described.

URINARY TRACT INFECTIONS The prevalence of women to nlen with bacteriuria progressively decreases with age and 20% of women and 10% of men over 65 years of age have bacteriuria. It is more prevalent in Genitourinary and institutionalised as compared to healthy donlicilliary subjects. Probability of urinary tract Endocrinological Disorders infection increases with the number of previous infections and decreases with an inverse proportion to the elapsed time between the first and second infections. Most reinfections occur after 2 weeks and within first 5 months of an isolated urinary tract infection. The risk of bacteriuriarernains the same, treatment appears to alterthe time until recurrence. The long tern1 effects of an uncomplicated recurrent urinary tract infections are not completely known.

2.2.1 Pathogenesis of Urinary Tract Infections You may remember fiom your undergraduate classes, that urinary tract infection is tlie result of imbalance between host resistance and virulence of bacteria. The infection is most frequently caused by gram negative enterobacteriae group of organisms. E. coli is the most common cause accounting for 85% of comnlunity acquired and 50% of hospital acquired infections. Other bacteria are Proteus, Klebsiella, E. faecalis and staphylococcus. Ascending infections is most common and most bacteria enter tl~eurinary tract from the faecal reservoir via urethra into the bladder. In 50% of instances of bladder infections there is further extension of infection into the upper urinary tract. This is greatly increased if bacteria have special adhesion (pilli) that interfere with nom~alureteral peristalsis and uretheral obstruction. An uncommon route is haemotogenous route where staphylococcus, aureus from oral sites and candida reach urinary tract through bacterimia. Direct extension of bacteria through lymphatics nlay occur from adjacent organs such as severe bowel obstruction or retroperitoneal abscesses. Factors which increase incidence of urinary tract infectioils are: lminunocompromised hosts (AIDS, Post renal transplantation, Lymphomas), Coexistent diseases such as malignancies and diabetes mellitus, Trauma. Imnlunosupressant drugs (glucocorticoids, cytotoxic drugs) foreign body, malnutrition and congenital diseases impairing phagocytic capacity of neutrophils. 2.2.2 Diagnosis of UTI Diagnosis of UTI is done on the basis of clinical history and urine analysis. a) Clinical Diagnosis You may already be aware of the symptoms of acute UTI. Urinary infection produces symptoms such as frequency of micturition, incontinence both urge and stress can clearly be caused by UTI. There may be haeinaturia. Lower abdominal tenderness on bimanual exmination in the bladder area may be present in lower UTI whereas fever, continuous pain in lumbar area or flanks indicate upper urinary infection. b) Laboratory Diagnosis Urine examination is routinely done to diagnose UTI. Collection of Urine You may recollect the method of collection of urine from your earlier student days. Patient is asked to self collect midurinary stream sample ofuriile in a clean sterile bottlc after cleaniilg the meatus in males. In females spread the labia, clean the vulva1 area from front to back with soap and tap water and dry with clean gauze. Don't use any antiseptic solutions as it may interfere with growth of bacteria if specimen is sent for culture. After initial few cc of urine, froin the midstream sample is collected in the bottle. The mouth of both should not touch any part of labia. The sample of urine is examined microscopically and sent for culture and sensitivity. Urine Anulysis

i) hficroscopy of Urine A clean catch mid stream first morning urine is collected as described earlier and isexanlined within one hour of collection. a Put one drop of urine on a clean slide, and place a coverslip over it. Look for pus cells Urologicnl Disorders under high power. If more than 6-7, pus cells are foundMPF, UTI is very likely. a About 10-15 ml of urine sl~ouldbe centrifuged for 5 min. at 3000 revolutions/inin. The supernatant is then poured off and the sediments is resuspended in the centrifuge tube. A small amount of fluid from tube is placed on microscopic slide and covered with cover slip. The slide is examined both under low power ( XI 00) and high power ( X400). The bacterial count should be approximately 30,000 ml before bacteria can be found in the sediments, stained or unstained. Therefore, negative urinanalysis never exclude the presence ofbacteria in numbers of 30,000 or less. Pyriuria and bacteriuria are commonly seen together. Bacteriuriawithout pyriuria is seen in asypmptomaticbacteriuria Pyuria without bacteriuria is more common and seen in tuberculosis of urinary tract, infection with chlamydia, or chemical cystitis. ii) Urine Culture Urine must be refrigerated immediately upon collection and should be cultured within 24 hours of refrigeration. The colony counts are done count of more than 1V are considered significant. However, this magic number need not be adhered in case of dysuric females. Cultures showing polymicrobial infection indicates contamination and needs to be repeated unless the patient is on in dwelling catheter, stones or tumour etc.

2.2.3 Management You must know about the common drugs used in acute UTI. The common antimicrobial used with their mechanism of action are shown in Table 2.1.

Table 2.1: Antimicrobials for Management of UTI with their Mechanisms of Actions

Drug or Drug Class Mechanism of action Mechanism of raisbecc

Beta-lactam (Pencillin Inhibit bacterial cell wall Alteration in binding sites cephal osporins) synthesis Production of beta Mamate

Aminoglycosides Inhibition of ribosomal protein Down reguiltion of uptakc synthesis. Bacterial production of modifying enzyme.

Quinolones Inhibition of bacterial DNA Mutation of gyrase- binding gYraee sites.

Nitrofurantoin Inhibition of several bacterial Change in cell wall protein enzyme eysteme size (decrease pnkration) Not fully understood

Trimethoprim- Antagonism of bacterial folate Draws folate from sulfamcthoxazole metnboliem environment, multiple levels Inhibit bactedal cell wall by production of diffcnnt eyntheeis. phenotype of protein.

Principles of antiinicrobial therapy are: e The treatment inust result in urine showing no bacterial growth. The concentration of antimicrobial sl~ouldbe highest in urine. e The choice of antimicrobial should be dictated by whether the infection is complicated or uncomplicated and spectrum of activity of antibiotic including its toxic effects. e A histoty of hypersensitivity, renal and hepatic functions should always be elicited before starting therapy.

Durntlon of Therapy This depends on the extent and duration of tissue invasion, achievable concentration of antimicrobial in wine and risk factors that impair the host and natural defence mechanisms. The peral guidelines are outline in Table 2.2. -

Genitourinary and Table General Guidelines for Duration Antimicrobial Therapy Endocrinological Disorders Uncomplicated urinary tract infection 3 days treatment Acute cystitis 3 days treatment Acute cystitis with persistence of symptoms 7 days treatment Age > 65 years 7 days treatment Diabetes mellitus 7 days treatment Acute uncomplicated pyelonephritis 10-14 days

Undved or complicated infections 10-21 days

Route of Administration There is no evidence that parenteral antibiotics are more effective than oral except in cases of very sick patients or intolerance to oral medications. Whenever patient can tolerate, oral medications should be started. Follow up ofpatient Following Treatment with Urinary Tract Infections You must make sure that the treatment was effective. For that make sure urine culture becomes sterile after 7-10 days of antimicrobialtreatment investigations are done to rule out underlying cause where ever indicated. rule out the problem associated with persistant presence of bacteriuria

Causes 01Unresolved Bacteriuria: Bacterial resistance to the drug used lor treatment. Development 01 resistance lrom initidly resistance bacteria. Rapid reinfection by new resistant species. Mied iulections (two or more org8'~). Amtemia (renal failan) Giant staghorn stones harbouring bacttria. Papillary necrosis.

Factors which increase morbidity and mortality in urinary tract infections are given below in Table 2.3. I Table 2.3: Factors Increasing the Morbidity and Mortality of UTI

a) Unilateral i) Stonca ii) Ureteral 6oturc iii) Pdviuretric junction obstnrction (PUJ)

b) Bilateral i) Eknign prostate ii) Hyperplasia iii) urethral striotures or iv) High pressure mrogcnic bladda.

c) Cougenit.1 mfnsny tract anomrb Non--g duplication of duplex syrrtcsn Urdcrocoda pdvicalyced divcrticuli.

Cathter Drainage Urinary tract infections account for 40% of nosocomial infections, The most common predisposing cause of nosocomial urinary tract infection and gram negative bacteremia in hospital patients is catheter associated bacteriuria. The incidence of urinary tract infection is directly associated with the duration of catheter 95% of the patients become bacteriwic within Urological Disorders 4 days of catheterization. However, there is no benefit of treating asymptomatic bladder bacteriuria in patients on prolonged catheterization except for urea splitting organisms which require treatment for 3 -5 days. Conditions requiring radiological investigations in UTI are listed in Table 2.4.

Table 2.4: Indications of Radiological Investigations in Acute Urinary lhct Infection

History of stone disease Suspected ureteral obstruction (stone, stricture, tumour) Papillary necrosis (Diabdic, Sickle cell anemia) Poor response to antimicrobial treatment aRer 5-6 days of treatment Neuropathic bladder (history suggestive of lower urinary tract obstructive symptoms) Unusual organisms as tuberculosis or hngus, prdcus Diabetes mellitus

Complicated Urinary *act Infections Infection that occur is a patient with abnormal functional, metabolic or anatomic urinary tract. Infection caused by resistant organisms to most antibiotics is also included in this category. The clinical spectrum range from cystitis to wosepsis. Duration of drug therapy is prolonged for 3 or more weeks. Conditions associated with complicated urinary infection is given in Table 2.5.

Table 2.5: Conditions Associated with Complicated Urinary 'ZtPct Infections (Increased Morbidity and Mortality)

Obstruction

Urea splitting organism that cause struvite stom

Congenital urinary tract anomalies

Catheter drainage

a Renal papillary necrosis

Diabetes

2.2.4 Recurrent Urinary Tract Infection You may know that lack of oestrogen is the common cause of recurrent UTI in women. You will be reading more about this in Unit 3 of this block. Other causes of recurrent UTI in women are: - Cystocele (anterior vaginal wall prolapse)-causes incompletebladder emptying - Anticholinergicmedications - Surgical overcorrection of stress incontinee - Faecal impaction - Impaired bladder function - Diabetes Causes of recurrent UTI in men are: - Acute and chronic prostatitis - Benign prostatic hypertrophy - Urinary retention - Diabetes Genitourinary and The complicated UTI also cause recurrent UTI : Endocrinological Disorders Prolonged prophylactic therapy with one of following drug should be chosen:

Trimethoprim- sdfhethoxazole (TMP- SMX) ) One daily for 3 months Trimedqrh 100 mg once daily for 6 months Nitrofurantoin 100 mg once daily for 6 months Cephalexins 250 mg once daily for 6 months Ciprofloxacin 200 mg once daily for 6 months Prophylactic therapy can be extended upto 1 year depending on clinical response. In reliable cases intermittent self start therapy of prophylaxis is recommended. Flouroquinolones are the ideal drugs for self therapy. General Measures It includes hygiene and local estrogen creams in post menopausal females and increased oral fluids especially during day time ( to avoid nocturia)

2.3 RENAL FAILURE 4 In this section, you will be reading about renal failure, both acute and chtonic.

Renal failure is defined as the deterioration in renal hction wflicient to result in accumulation of nitrogenous waste in the body. This can occur either rapidly (acute renal failure) or over a period of time (chronic renal failure). 2.3.1 Aetiology of Acute Renal Failure Urological Disorders rl Acute renal failure is seen in 5% of all hospitalised patients and incrkases the likelihood of fatal outcome by eight folds in these patients. The main stress should be on prevention and early detection of this clinical entity. Acute renal failure could be caused by many insults or a combination ofthese. Most commonly it is caused by decreased renal perhsion .

Clinically causes of ARF is classified into pre renal, post renal and renal (Table 2.6). Assignment of patient to particular group requires a combination of clinical, laboratory evaluation and imaging studies. The management differs in each category, hence it is of clinical importance.

Table 2.6: Clinical Causes of ARF a) Prerend Hypovolemia - Haemorrhage (concealed or revealed) Blood loss GI loss and Na depletion - Diarrhoea, vomitting Volume redistribution - Burns, pancreatitis, peritonitis, excessive sweating Renal loss of fluids - Diuretic therapy, salt loosing nephritis Peripheral vasodilation - Sepsis, anaphylaxis Decreased cardiac output - Cong. heart failure, cardiomyopathy, pulmonary embolism Intrarenal hemodynamic - ACE inhibitors, WSAIDS, hepatorenal syndrome. b) Post Renal Bladder flow obstruction - Urethral obstruction (Stricture), Bladder outlet obstruction) posterior urethral valves, Prostate hyperplasia, prostate carcinoma, Detrusor sphincter dyssynergia in neurogenic bladder, stones and necrotic papilla. Ureteric Obstruction - Stones or Crystals (Uric acid oxalates, sulfonamide (Bilateral or single kidney) and rnethotrexae blood clots, tumoun, surgical ligation). C) Post Causes Glomemlar - Primary acute glomerulonephritis, immune complex diseases, DIC. Tubulointerstial - Acute 4 interstial 4 nephritis, Acute 4 tubular necrosis, nephrolithiasis, drugs (pencillins) radiation nephritis

Systemic diseases - Vascular diseases, sub-acute bacterial endocarditis, hemolytic ureamic syndrome, polyarteritis, nodosa, malignant hypertension.

Prerenal causes constitute 40-80% of the acute renal failure. You must remember that most of these causes are reversible if treated at proper time. Surgical trauma contributes to 2040% cases. Renal functions start deteriorating when perfussion pressure drops below 60 mm Hg. You might have realised by now that post renal is usually amenable to treatment, hence sllould be considered in all cases of renal failure. It usually constitutes 10% or less of all cases of acute renal failure.

Acute lh bulnr Necrosis It is the most important cause of renal failure. Majority of the cases are related to or trauma. The most common cause is ischaemia (haemorrhage, inm operative hypotension, cardiogeiuc shock, sepsis). It is the result of prolonged ischaenua. Nephrotosic drugs (radiographic contrast and aminologlycosides)can cause acute tubular necrosis. Rhabdomyolysis in trauma or in extensive bums can lead to this type of renal failure.

ARF can be oliguric (<40 ml urine ouputfday) or non-oliguric (<4Oml/day ). The non -01iguric renal failure has a better prognosis than oliguric failure. Genitourinary and 2.3.2 Approach to Patient of Acute Renal Failure Endocrinological Dlrordbrs This sub-section deals with the way a patient of ARF is approached.

Clinical Features of Acute Renal Failure

Complete anuria is unlikely to be due to renal tubular necrosis. Fluctuation in urinary ouput suggest intermittent urinary obstruction. Polyuna can be hallmark of partial urinary obstruction. Praious history of renal failures due todrug intake (arninoglycosides, pencillins, sulfonamides, NSAIDS) indicates drug induced renal failure.

Examination of Urinary Sediments Sediments with formed element or only hyaline casts suggest pre renal azotemia or obstructive uropathy. Acute tubular necrosis is suggested by the presence of renal tubular epithelial cells and pigmented cellular casts. The presence of large number of polyrnorphs leukocytes singly or in clumps suggests diffuse intersitial nephritis. Treating biochemical composition of urine is helpful in differentiating prerenal and renal causes of renal failure as in Table 2.7.

Table 2.7: Biochemical Composition of Urine in Renal Failure

Urine' plasm cmtinc

Fraction exwetion of Ndor occassional brown granular cast,

Imaging in Acute Renal Failure

Renal ultrasonography differentiates between obstructive and non- obstructive renal failure with fair accuracy. A 20% of false positive incidence have been reported secondary to extrarenal pelvis. With the introduction of doppler ultrasound, the accuracy has increased. To localise an obstructing lesion, antegrade (via PCN) or retrograde studies are required. Renal scans are necessary in kidney transplant graft dysfunction to differentiate between cyclosporin toxicity and acute rejection.

2.3.3 Management ofAcute Renal Failure The management of acute renal failure consists of general management conservative therapy and the treatment of hyperkalimia.

1) General Management All specific treatable causes of decreasing renal functions are identified and treated such as: Blood volume expansion in hypovolemia Diuretics like mannitol. fiusemi& Treating associated infection Rigorous fluid replacement in patients undergoing surgery a Recumng nepluotoxic drugs or patients undergoing radiocontrast studies. 2) Can.smvativeTherapy Decrease intake of nitrogen, water and electrolytes to match output. a Provide adequate nutrition Adjust dose of drugs Urological Disordel.. Maintain clinical moilitoring (vitals, intake and output, body weight, wound illspection if any) Maintain biochemical monitoring (creatinine, electrolytes, blood counts will be dictated by patients general condition)

3) Treatment of Hyperkalernia Emergency trcatnlent:

10 nll of 10% calcium chloride solution intravenously over 2 minutes. Sodium bicarbonate 50 nll(44 mmol ) intravenously over 5 min. 200-300 nll of 20% glucose with 20-30 units of plain insulin intravenously over 30 min.

Non-emergency treatment:

Sodium polystyrene sulfonate 50 gm with 100 ml or sorbitol every 3-4 hours (enema in cases who cannot tolerate)

The patient may be referred for dialysis when:

Symptomaticuremia (central nervous or gastrointestinal symptoms) develops There is a development of resistant hyperkalemia. Severe acidosis and fluid over load not responding to medical therapy. Pericarditis sets in

2.3.4 Chronic Renal Failure (CRF)

Chronic rcnal failure is iilsidious in onset and most of the patients do not know until blood assays of BUN blood urca and serum creatinine are obtained as a part of routine chemical screen.

i) Clinical Prcsentation and Aetiology of CRF Patients of CRF generally colnplains of fatigue, sleep disturbance, nausea and vomitting or puritis. Evidence of anaemia, hypertension or left ventricular hypertrophy is usually present. Proteinuria or inicroscopic evidence of casts or blood in urine may be detected in urine. You must be aware of the comnon causes of chronic renal failure and look for it in the patients wit11 following ailments: Diabetic nepllropatlly Hypertension Gloniemlonephritis Polcystic kidney disease Miscellaneous. reflux neuropatlly, bergers disease, medullary cystic disease, analgesic ~lephropatlly,nlinilnal change disease, Amylodosis, SLE, collagen, vascular diseases. ii) In\restigations and Management of CRF You may apply for the following strategies to investigate a patient of CRF: Establish prinlary cause Escludc reversible insult to renal functions. If renal iailure has not advanced to end stage renal disease and the kidneys are not small, biopsy sllould be done to find treatable cause.

lil) Conservative 'hntment of Chronic Renal Failurn a) Diet sllould be modified, consisting 0.6 gramof pmtein per kilogram body weight preferably co~itniningketoanlinoacids and energy 3.5 KcaVkg/day, Grt~itourinary and Table 2.8: Recommendations for Dietary Modifications Based on Degree of Chronic Renal Failure Endocrinological Disorders GFR dialysis 2 70 ml 70-25 ml 25-5 ml (Minf1.73m2 )

Proteins 1.4 Normal 0.6 0.6+ supplement* (gm WW)

Energy>35 2 35 2 35' 135 ( KaVkg)

Carbohydmtm 50% 5Wo 50% 50% (%oftotaf)

Fat 20% 20% 200/0 20% (%ofW)

* Supplement with essential fatty acids and ketc-aminoacids With nephrotic syndrome, proteins are supplemented as: 0.8 +urinary proteins in gram b) Control of hypertension c) Management of electrolyte disturbance ( hyperkalemia2 hyponatremia) d) Hyperphosphatemia with hypocalcemia should be corrected using calcium containing phosphate binders such as calcium carbonates with meals.

iv) Renal Replacement 'Iberapy You may consider renal transplant in the following situations: 1) Development of complications such as pericarditis, sensory neuropathy. 2) End stage renal disease which is usually defined as an irreversible decrease of glomerular filteration rate below 10 mVmin. and a serum creatinine level of more than 8 mgldl. Contradictions to renal transplant: Reversible renal involvement Advanced form of extra renal complication like cerebrovascular disease, ischaemic heart disease, hepatic disease Active infection, HIV disease Positive cross match with donor Psychiatric diseases Oxalosis, infrafemoral occlusive disease. Urological Disorders

2.4 DISEASES OF THE PROSTATE 1 The prostate is a fibromuscular and glandular organ. It is a pramidal (compressed inverted cone) structure situated in the true pelvis, in the area of the bladder neck. Posteriorly, it is next to the rectum. The normal prostate weighs about 12 - 20 gms and containsthe posterior urethra which is called as prostatic urethra and is of 2.5 cm in length. The normal dimensions of the I prostate are 3.5 x 2.5 x 2.5 cms (transverse x vertical x anteroposterior). It has got 5 lobes: anterior, posterior, median, right lateral and left lateral. McNeal(1972) divided prostate into zones: peripheral zone (makes 70% of the gland), central zone (makes 20% of the gland), central zone (makes 5-10% of the gland), an anterior segment and a preprostatic sphincter I zone. Anterior fibromuscular

Fig. 2.1: Prostate

The specific function of the prostate has not been specdied clearly, but it provides the bulk of the ejaculate. The secretion of the prostate includes nutrients for sperms and protease (enzyme) which function to liquefy the ejaculate. It is likely that many other functions have not been I identified. I Prostate is an important organ in man and problems may arise as the person is aging: I Benign hypertrophy of prostate (BPH) Prostatitis I Prostatic abscess Cancer ( Carcinoma) of the prostate I You should be able to diagnose the above conditions Genitourinary and 2.4.1 Benign Hypertrophy ofprostate ( BPH) Endocrinological Disorders This is a progressively worsening condition associated with the aging. with an onset in forties due to the enlargement of the gland itself. Pathophysiology of BPH The symptoms secondary to the enlarged prostate gland is due to the combination of various factors described below:

1) Mechanical Obstruction (Static Component) This is because of the enlarged prostate gland itself, i.e., the tissue by which the gland is formed itself. This is called the epithelial component and acts under the influence of androgens (male hormone). The androgen blocking drugs are used to take care ofthis part of the prostate gland. The commonly used drug for this purpose is finasteride. 2) Dynamic Obstruction This is because of the following components of the prostate gland: (a) surrounding capsule of the prostate gland, (b) smooth muscle fibres, and (c) collagen tissue. I These components have got special appendages formed of highly specialised proteins which are called as receptors (alpha-receptors) which contract these structures and obstruct the urinary flow. This action of alpha receptors is blocked by the drugs called as alpha-blockers. Clinical Feature BPH can cause symptoms which can be divided into three broad categories:

1) Obstructive Symptoms

Weakness of urinary stream Hesitancy (delay in starting urination) Terminal dribbling (dripping of urine after completion of urinary act) Intermittency (Interruption of the urinary stream) a Sensation of incomplete bladder emptying Straining to urinate

2) Irritative Symptoms

a Urinary urgency (intense desire to pass urine) a Frequency (passage of urine many times in day and night) a Nocturia (patient is compelled to get up in the night to pass urine) a Incontinence (leakage of urine involuntarily at times)

a Hematuria (passage ofblood in the urine) a Urinary tract infection a Urinary retention ( at times) a Kidney failure in severe obstruction

Diagnosis , You learn to diagnose BPH by clinical features, examinations and certain procedures as mentioned below: 1) Rectal examination:This is done by putting index finger into the rectum of the patient. In BPH the prostate gland is usually enlarged, but sometimes a small gland can also give rise to urinaryproblem. Urologieal Disorders 2) Uroflowmetry:This is the measurement of speed of the urine by a computerised machine (Fig 22). -

v\volume

Fig. 2.2: Uroflowmetry 3) Ultrasonography:This is done to know the size of the prostate gland, shape and capacity of the bladder and the urine left in the urinary bladder after urination, i.e., post void residual urine ( PVR). 4) Symptom Score: This is the total of the marks calculated according to the symptoms. There are various symptom scores available to assess the severity of the disease where each symptom is given mark according to the severity the disease starting from I to 5. The table and its calculation are beyond the scope of this course.

5) Cysfosopy: This is the direct inspection of the prostate gland with the help of a telescope and this is usually done at the time of surgery. Complicstions In addition to the significant symptoms that develop, BPH can result in more complications like the development of bladder stone, urinary retention, dilatation of ureters and kidneys (i.e. hydronephrosis) and in severe cases kidney failure. Several of these conditions respond to the treatment ( e.g. urinary retention and bladder stone), but others may be permanent (renal failure) and may not respond to removal of the obstructing prostate. Management of BPH You must learn about BPH as it is very common in elderly men. Treatment depends on the severity of symptoms. The patients with mild symptoms may be observed. However, those with Werate to severe symptoms require some form of therapy. Other indications for the treatment rqlate to the complications associated with BPH, such as urinary tract infection, bladder, stonb, urinary retention, dilatation of ureters and kidneys ( hydronephrosis). Until recently, surgery was the main stay of therapy for BPH. In the last decade or so there has been a tremendous resurgence of interest in non-surgical . The different forms of the therapies available with us are as follows: 1) Medical Treatment i) Drugs: Prostate gland has got very fme structures in it which hslve been named as receptors ( alpha-receptors), by blocking the action of these receptors we can reduce the size of the gland and thus helping the patient to pass urine. The various drugs available in the market are prazocin, teramcin, doxazocin and many more. These drugs are usually taken once in a day at bed time. ii) Anfi-undrogenDrug :For the treatment ofthe BPH anti-androgens are usell. FM& is the drug, which is used to block the conversion of male hormone, testosterone in to the other chemical called as dihydrosterone responsible for the growth of the prostate. This drug is taken in the dose of 5 mg once a day. 2) Surgical Treatment You may refer to institutionswhen surgery is required. In the past prostate gland was removed by giving a skim incision in the lower part of the abdomen. But now-a-days, it is mainly done through the route of uretlm+e., without cutting the skin. The various modes ofthese through the urethra are depcribed below. Genitourinary and a) 7kansumthral Pmstatectomy (TURP) Endocrinologieol Dinorders Here we pass a telescope with a resector through the urethra (cystoscope) and remove the prostate by cutting it in the foms of small chips. After removal of the prostate a draining catheter is kept in to the urethra for a day or so and patient is usually discharged from the hospital in two or three days. b) Balloon Dilatation of the Prostate The procedure errsentially involves the use of non-compliance balloons to dilate the prostate under pressure. The balloon compresses the gland and widens the passage of the urethra. This techniqw is good only for small to medium sized glands only and will not be effective in very large glands, sa it is not used now-adays. c) Microwave Hyperthermia This is heat induced time damage. Here, we use a microwave probe either through the urethra or though the rectum to heat the prostate to achieve a temperature of 42-45 OC. d) Prostate Stents These are metallic permanent indwelling prosthesis (tubes/coils) which are kept into the urethra in the area of the prostate. By this the site of obstruction is bypassed and patient starts voiding. 3) WatckJuZl Wait This is simple observation and follow up of the patient in cases of mildly enlarged gland and minimally symptomatic disease. This is done by comparing a symptom score chart and uroflowmetry done at three to six months interval. 2.4.2 Prostatitis Prostatitis is a combination of infection and inflammation of the prostate and presents with the features of dysuria, i.e., acuity invoiding, increased frequency of micturition, perineal pain and pain with ejaculation. Prostatitis is of two types: 1) Bacterial

Organisms causing prostatitis: Bacterial Gonococcal prostatitis Tuberculouis prostatitis

Parasitic prostatitis Fungal prostatitis Non-specific granulomatous prostatitis Diagnosis Diagnosis is made-by rectal examination and laboratory tests: Rectal Examination Rectal palpation shows the tender ( painful), swollen prostate gland that is fum,indurated and warn onfouch. Laboratory Tests Examination of the urine shows plenty of pus cells and urine culture may show an infective organism.

Prostatitis is treated in the following way: 1) Antibiotic Urologicsl Disorders The most commonly used antibiotic agent is uimethoprimsul~methoxazole.Given otally in a dose of 160-180 mg twice daily. In a sulfa-allergic patient, ciprofloxacin (a fluroquinolone), 500 mg twice a daily.

2) Anti-infammatory and analgesic a (pain killer) This is given to give relief from the pain as wel1,asto counter the inflammation. 3) Sitzebdh This is a practice to sit in small tub with luke warm water to dip the perineum, this relieves the prostatic congestion as well as it helps in relieving the pain in the perineum. Be careful to avoid any urethral manipulation. 2.4.3 Prostatic Abscess

Prostatic Abscess a serious, life threatening infection of the' prostate usually seen in the patients with compromised, immunity diabetes and kidney failure. Thia is the infection of the prostate resulting in the formation of pus in the gland. Clinical Features Fever Pain in the perineal area Dysuria, i.e. difficulty in urination

Retention of urine ( at times) Predisposing Factors

Urinaty ttact infection ( long standing) Obdonin any part of the un&m lkatment Patient its treated by mgical drab@. Thia is done by draining (incising) the pus tfbm the prostate thmugh the urethra. Wide apeanun antibiotics are presnibed. Anti -inflammatory and arlalgesics are given to relieve arymptom Plentyof~fluidsaretobetskt?n. 2.4.4 Cancer of the Prostate is a dieease of aging. It rarely occurs in man under the age of 40 and its incidence increases progressively until it reaches a peek in the eighth decade. Proatate cancer is one of the mow common cancers in the elderly. You will be reading more about it in Unit 2, Block7of Goune2. The various fwrswhich have been attributed in the causation of cardnoma p-te are as follows: Genetics :Qenetic alterations in the form of 1086 af genetic matetiela an certain chmmbswnes (genome) have been attributed in the cawtion of this cancer. Familial :The relative risk of having cancer of prostate in- if one or the more first- degree relative has the disease. + Hormonal : Slight variations (elevations) in the androgen lev& in the man have been condated with the development of this disease. Diagnosis Dirrmosis is mRde bv clinical hture.. and invatieaticms The men usually present with one or more ofthe following symptoms and signs:

-tion of urine (at times) A nodule in the prostate on palpation though the rectum. Inv~'g&nS The following investigations are done to confirm the disease: Prostate Specijic Antigen (PSA) This is a prostatic protein which is umally measured in nanograms and its normal prostatic conditions is less than 4 ng/ml in cancer it is increased many folds. Prostatic Biopsy This is the removal of a tiny piece from the prostate by a fine needle passed through the rectmn to find out the cancer in it. X-ray Pelvis and Lumboscral Spine Cancer of prostate is peculiar in the sense that it has a tmdenq to.spreadto the bones (spedlythe pelvic bones and the spine). This is done to find the sped of the cancer into the bones. Bone Scan This is again done to pi& up seamhies (bone spread) in thebom. This is done with tbe belp of a spedised radioactive compound called Tc, labled methyiene diphosphonate which is specially taken up by bones. At the site of cancer, it shows inneased up-take.

You must know the various treatment nndalities that are available.

In the early stage of the disease (usually in a younger patient) this cancer is treated by radical prostatectomy.

Radiation is usually given in a localised disease when we do not want to remove the pmtate.

As we know that the prostate amem has been oomlated with tbe elevated levelr of malc hormones, i.e., androgens, so it is tried to reduce or stop the availability of these hormones. Thevari~~~methodsbyw~hthiscanbeachieved~by~ogboththetestes(B~ orchiectomy). This removes tbe source of male brmonic takwkmne. Oral tablets to teduce the adabi& ofkhormoaeg viz. Flubmi& (a&dmga) and dierhylstiks&ol (estrogen) etc. ate also mamma&d. Radioactive phosphorus or strontium. Urolugical Disorders

Check Your Progress 3

1) Name the three broad categories of symptoms caused by BPH.

2) List the two group of drugs used in BPH.

3) State Tme or False.

a) Most commonly used antibacterial drug in prostatitis is trimethopgrim- Sulphamethoxazolecombination flm b) Non- bacterial prostatitis also include tubercular prostatitis. V/F)

c) Predisposing factors for prostatitis include prolonged UTI. (Tm

d) Prostate abscess is mainly treated by broad spectrum antibiotics and analgesics. Crm

4) Enumerate the three treatment modalities available for cancer prostate.

2.5 LET US SUM UP

In this unit, you read about the urinary tract infection. Their diagnosis and management including complicated and recurrent UTI. The causes and management of acute and chronic renal failure are also dealt with you. You may be quite aware of the urinary problems and various other symptoms caused by diseases of prostate in the elderly male mainly benign prostate hypertrophy and prostate cancer. Diagnosis and treatment modalities have been discussed.

2.6 KEY WORDS

Acute Renal Failure : Sudden deterioration in renal function sufficient to result in accumulation of nitrogenous waste in the body. Chronic Renal Failure : Insidious in onset leading to gradual deterioration in renal functions which occurs in six months to one year duration. Genitourinary and Complicated Urinary1 'kact Infection : Infections in a patient with functionally or Endocrinological structurally abnormal urinary tract. Infection is Disorders caused by a bacteria that are resistant to many antibacterials. Nosocomal Infections : Patients which are hospitalised or insti- tutionalised. These are usually caused by Pseudomonas and other more antimicrobial resistant strains. , Recurrent Infections : Reinfection applies either to infection froin outside the urinary- tract or to bacterial persistence within the urinary tract. TURP : Trans urethral resection of the prostate. Uncomplicated Infection : Infection in a patient with structurally and functionally normal urinary tract. UTI (Urinary Tract Infection) : It is inflammatory response of urothelium to bacterial invasion usually associated with bacteri~viaand pyuria.

2.7 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1 1) a) ascending b) Midstream c) asymptomatic patients. 2) Tuberculosis of urinary tract Chylamydial infection Chemical cystitis. 3) Urine-routine examination Urine culture and sensitivity.

4) The drugs commonly used in treatment of UTI are quinolones, aminoglycosides, nitrofurantoin, pencillin and cephalosporinsand trimethoprinl- sulfamethoxazole. Check Your Progress 2

1) Hypovolemia, peripheral vasodilatation, decreased cardiac output and intrarenal haemodynamic changes caused by drugs.

2) Oliguria is defined as the condition wheu urinary output is less than 400 ml 3) Common causes of chronic renal failure are diabetic nephropathy, hypertension, glomerulonephritis, polycyptic kidneys and collagen diseases. 4) 3 Dietary modification ii) Control of hypertension

iii) Management of electrolyte disturbances ( hyper and hypokalemia)

iv) Management of hyperphosphatemia and hypocaleaemia. Check Your Progress 3 1) 3 Obstructive symptoms ii) Irritating symptoms iii) Other miscellaneous symptoms such as haematuria, retention of urine and kidne! failure. 2) i) Drugs blocking alpha receptors e.g. prazocin, terazocin, doxazocin. Urological Disorders ii) Antiandrogens-Finasteride.

4) i) Surgery ii) Radiotherapy iii) Hormonal therapy

2.8 FURTHER READING

Fauci, Braunwald, Isselbacher, et al. (eds.),Harrson 's Principles of Internal ,&tedicine,14th edition, International edition-Mcgraw Hill Publishers, 1998.