Common Benign Disorders of Bladder and Urethra 陳 宏 一 Hong-I, Chen, M.D., PhD., M.M.M., EMBA 軍醫局 局長 (2004--2008) 三 軍 總 醫 院 院 長 (2001-2004) 國 防 醫 學 院 醫 學 系 M67 (1973) 英 國 牛 津 大 學 神經藥理學 博 士 (1990) 美 國 杜 蘭 大 學 醫務管理 碩士 (2000) 國 立 台 灣 大 學 管理學院 EMBA (2006) H.I. Chen 1 Disorder of the Bladder, Prostate, Urethra, Seminal Vesicle, Penis, & Genitalia ◆ Anatomy and Histology (LOW URINARY TRACT) ◆ Physiology and Pharmacology ◆ Disorder ◆ Diagnosis and Treatment ◆ Prognosis H.I. Chen 2 Anatomy H.I. Chen 3 Prostate: blood supply H.I. Chen 4 H.I. Chen 5 H.I. Chen 6 H.I. Chen 7 H.I. Chen 8 H.I. Chen 9 H.I. Chen 10 Bladder : Disorders, Diagnosis & Treatment, Prognosis (interstitial cystitis) ◆ Acquired diseases of the bladder: A. Interstitial cystitis (Hunner’s ulcer, submucous fibrosis): a. fibrosis of the vesical wall, middle aged woman, loss of bladder capacity. b. frequency, urgency, nocturia and pelvic pain with bladder distention, urine is usually normal. c. small ulcers or cracks in the mucous membrane. d. microscopic hematuria may be noted. H.I. Chen 11 Bladder : Disorders, Diagnosis & Treatment, Prognosis (interstitial cystitis) e. ureterovesical junctions is destroyed, leading to vesicalureteral reflux, hydroureteronephrosis and pyelonephritis may then ensue. f. cystoscopy is usually diagnostic, as the bladder fills, increasing suprapubic pain is experienced. g. Treatment: There appears to be no definitive treatment for interstitial cystitis. H.I. Chen 12 Bladder : Disorders, Diagnosis & Treatment, Prognosis (interstitial cystitis) @ hydraulic overdistention with or without anesthesia. @ vesical ravage (instillation, irrigation) with silver nitrate (1:5000-1:100), or 50ml of 50% dimethyl sulfoxide (DMSO), or 0.4% oxychlorosene sodium (Clorpactin WCS-90). @ orally, sodium pentosanpolysulfate (Elmiron), or cortisone acetate, or prednisone, or antihistamines. Heparin sodium 20,000 u. (i.v.) H.I. Chen 13 Bladder : Disorders, Diagnosis & Treatment, Prognosis (stress incontinence) B. Stress incontinence: a. the loss of urine with physical strain (eg. coughing, sneezing). b. common in older women of childbirth. c. the basic lesion is loss of normal midurethral resistance caused by a severe sagging of the vesical base and urethra due to poor support of these structures. d. urethral pressure studies show little closure pressure in the proximal half of the urethra. H.I. Chen 14 Bladder : Disorders, Diagnosis & Treatment, Prognosis (stress incontinence) e. the posterior urethra and bladder neck has fallen out of true pelvis, so that increased intravesical pressure & associated with decreased resistance in the proximal & mid urethra. f. the diagnosis of true stress incontinence is the lateral cystogram taken both with and without straining, in normal female, the base of bladder lies about 2 cm above a line drawn from the inferior margin of the pubis to the sacrococcygeal joint (SCIPP line), with straining, the vesical base should descend no more than 1.5 cm. H.I. Chen 15 Bladder : Disorders, Diagnosis & Treatment, Prognosis (stress incontinence) g. Treatment: @ estrogens locally or orally if the degree of incontinence is mild. @ retropubic urethrovesical suspension (Marshall- Marchetti operation) @ endoscopic urethrovesical suspension (Stamey procedure). h. Prognosis: the cure rate approaches 85-90%. Reoperation for recurrence case is necessary. H.I. Chen 16 Seminal vesicles: Anatomy & Histology ◆ The seminal vesicles lie just cephalad to the prostate under the base of bladder. ◆ About 6 cm long and quite soft, each vesicale joints its corresponding vas deferens to form the ejaculatory duct. ◆ The mucous membrane is pseudostratified, blood supply is similar to prostate: inferior vesical a., internal pudendal & middle rectal (hemorrhoidal) a. nerve supply is mainly from sympathetic plexus. H.I. Chen 17 Prostate & Seminal Vesicle H.I. Chen 18 Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis A. Congenital disorder: rare. B. Blood ejaculation (hemospermia) : a. it is a not uncommon complaint of middle-aged men, some caused by hyperplasia of mucosa of seminal vesicles. b. diethylstilbestrol 5 mg/day for one week has been suggested. c. infection of seminal vesicles is not possible to obtain diagnostic methods. C. Acute bacterial prostatitis: a. mainly caused by aerobic gram(-)--E. Coli and Pseudomonas. H.I. Chen 19 Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis b. possible route:1. Ascent from urethra, 2. Reflux of infected urine into prostatic ducts that empty into posterior urethra, 3. Direct extension or lymphatogenous spread of bacteria from rectum, 4. Hemoatognous spread. c. acute prostatitis is usually associated with acute cystitis & results in acute urinary retention, may resolve completely in response to appropriate therapy or may progress to abscess formation. H.I. Chen 20 Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis d. symptoms: chill and fever, low back and perineal pain, urinary urgency and frequency, nocturia, dysuria and varying degrees of bladder outlet obstruction, both myalgia and arthralgia are common. e. signs: rectal palpation typically discloses an tender, swollen prostate prostate gland is firm indurated and warm, urine may be cloudy. f. laboratory finding: leukocytosis, pyuria, microhematuria, bacilluria, urine culture may be positive. Prostatic massage is contraindicated. H.I. Chen 21 Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis g. Treatment: transurethral instrumentation is contraindicated during acute infection. Antibiotics usually gram-negative rods( gentamycin or tobramycin plus ampicillin. h. Prognosis: unless septicemia and septic shock, prognosis usually is good with appropriate therapy. Complication: marked swelling of prostate with acute prostatitis lead to acute urinary retention, requiring bladder drainage is best managed by the insertion of a punch suprapubic tube until inflammation subsides and patient can void by himself. H.I. Chen 22 Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis D. Chronic bacterial prostatitis: a. caused by one or more specific bacteria, typical causative agents are gram- negative aerobes: E.Coli, or Pseudomonas. b. the possible routes of infection are the same in acute and usual from acute bacterial prostatitis. c. symptoms: varying degrees of irritative voiding dysfunction(urgency, frequency, nocturia, dysuria) and lower back or perineal pain;myalgia or arthralgia. H.I. Chen 23 Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis d. sign: on rectal examination, the prostate may feel normal, boggy, or focally indurated, initial or terminal hematuria, hemospermia and urethral discharge are unusual findings,secondary epididymitis sometimes is associated with chronic bacterial prostatitis. e. laboratory finding: WBC usually normal, prostatic secretions obtained by prostatic massage typically show excessive numbers of inflammatory cells. H.I. Chen 24 Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis f. Treatment: 1. General measures: hot sitz baths. Discomfort and painful urination may response to anti- inflammatory agents (indomethacin, ibuprofen) and anti-cholinergic drugs(oxbutynin chloride, propantheline bromide). 2. Medical measures: antimicrobial agents (trimethoprim, minocycline, erythromycin). 3. Surgical measure: Transurethral resection of prostate (TURP). g. Prognosis: difficult to cure permanent, but recurrent urinary tract infections generally can be controlled by suppressive antimicrobial therapy. H.I. Chen 25 Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis E. Prostatic abscess: a. in recent years, the incidence of prostatic abscess has decreased and the type of infecting organism has changed. b. 50 years ago, 75% of prostatic abscesses were caused by gonococci. More recently, about 70% caused by E.Coli. c. most cases occur in the fifth or sixth decade of life, the pathogenesis remains unclear, are probably complications of acute bacterial prostatitis. e. symptoms & signs are mimic acute bacterial prostatitis. H.I. Chen 26 Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis f. Treatment: 1. The abscess can rupture spontaneously into urethra, preferred treatment consists of surgical drainage combined with appropriate antimicrobial therapy. 2. Drainage by transperineal insertion of a large-bore needle or perineal incision often is necessary for adequate drainage. With proper diagnosis and therapy, the prognosis is good, recurrent abscesses are rare. H.I. Chen 27 Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis Hypospadias: a. urethral meatus opens on the ventral side of the penis proximal to the tip of the glans penis. b. occurs in one in every 300 male children, estrogrens and progestins given during pregnancy are known to increase the incidence. c. classification: (1) glandular, ie, opening on the proximal glans penis; (2) corona, ie, opening at the coronal sulcus; (3) penile shaft; (4) penoscrotal; (5) perineal. About 70% of all cases of hypospadias are distal penile or coronal. d. hypospadias is evidence of feminization (intersex problem). H.I. Chen 28 Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis e. symptoms: 1. difficulty directing the urinary stream and stream spraying, 2. Chordee (curvature of the penis) will cause ventral bending and bowing of the penile shaft, which can prevent sexual intercourse, 3.perineal or