is the field of medicine that focuses on the urinary tracts of males and
females, and on the reproductive system of males. In men, the urinary
system overlaps with the reproductive system, and in women the urinary
tract opens into the vulva. In both sexes, the urinary and reproductive
tracts are close together, and disorders of one often affect the other.
The organs covered by urology include the kidneys, ureters, urinary
bladder, urethra, and the male reproductive organs (testes, epididymis,
vas deferens, seminal vesicles, prostate and penis).
The discipline combines management of medical
(i.e., non-surgical) problems such as urinary infections, and surgical
problems such as the correction of congenital abnormalities and the
surgical management of cancers. Such abnormalities within the genital
region are called genitourinary disorders.
Urologists are also involved in the assessment
and treatment of incontinence. Urodynamics is the study of the pressure
within the urinary system and urologists often use diagnostic techniques
such as flow cystometry or ambulatory urodynamic profiles to determine
the best method of treatment for the patient. This could include medical
prescription (e.g. oxybutynin or multiple alpha-blockers) or surgical
intervention (e.g. urethral suspension/slings).
Other subfields of urology include urologic
oncology, stone disease, voiding dysfunction, pediatric urology, sexual
dysfunction and male infertility.
Urology is closely related to the medical fields
of nephrology, andrology, gynecology, proctology and oncology.
How Urologists Were
Consumers' Research Council
of America has compiled a list of Urologists throughout the United States by
utilizing a point value system. This method uses a point value for criteria that
we deemed valuable in determining top health care professionals.
The criteria that was used
and assessed a point value is as follows:
Each year the Urologist has been in practice
and Continuing Education
in Professional Medical Associations
Completing an approved residency program and
passing a rigid examination on that specialty
Urologists that have accumulated a certain amount
of points qualified for the list. This does not mean that doctors that did not
accumulate enough points are not good
Urologists; they merely did not qualify
for this list because of the points needed for qualification.
Similar studies have been
done with other professions using a survey system. This type of study would ask
fellow professionals whom they would recommend. We found this method to be more
of a popularity contest. For instance, professionals who work in a large office
have much more of a chance of being mentioned as opposed to a professional who
has a small private practice. In addition, many professionals have a financial
arrangement for back-and-forth referrals. For these reasons, we developed the
point value system.
Since this is a subjective
call, there is no study that is 100% accurate. As with any profession, there
will be some degree of variance in opinion. If you survey 100 patients of a
particular Physician on their level of satisfaction, you
will undoubtedly hear that some are very satisfied, some moderately satisfied
and some dissatisfied. This is really quite normal.
We feel that a point value
system takes out the personal and emotional factor and deals with factual
criteria. We have made certain assumptions. For example, we feel that the more
years in practice is better than less years in practice; more education is
better than less education, being board certified is better than not being
The Top Urologist list that we have compiled is current as of a certain date and
other doctors may have qualified since that date. Nonetheless, we feel that the
list of top Urologists is a good starting point for you to find a qualified
family health care specialist.
No fees, donations,
sponsorships or advertising are accepted from any individuals, professionals,
corporations or associations. This policy is strictly adhered to, ensuring an
Finding a Urologist
Choosing a Urologist is an important decision. Thus, our goal is to assist you in making that decision.
First of all, when selecting a Urologist, you may want to begin your search
several different ways:
||Ask family, friends,
neighbors and/or co-workers.
||Contact your local
Chamber of Commerce or Better Business Bureau for reputable Physicians
that specialize in the area of medicine that you have a need for.
||Contact your city,
county or state medical agencies for names of qualified Urologists.
Contact and ask for referrals from medical associations. Many are listed
in this publication.
||Ask your family
doctor. They are in constant contact with all kinds of health care
professionals and will be able to provide you with recommendations.
We recommend that
you interview the Urologist and ask the following:
How long have you
been in practice?
Is your staff
friendly and accommodating?
What are the
procedures if we need a doctor in the middle of the night or on a
Do you have an
associate that covers for you when you are not available?
Do you have more
than one office and if so, how is your time divided between offices?
What kind of
continuing education do you utilize?
Do you accept phone
calls during office hours?
How do you stay
current on the latest drug prescriptions available and medical
What types of
insurance coverage do you accept?
How do you handle
billing? Do you require payment at the time of visit?
Discuss your family
medical history and particular problems you are concerned about.
After you have
consulted a few Urologists you should have a good idea which one you
felt most comfortable with and whom best answered your questions.
The prostate is a male reproductive organ which
helps make and store seminal fluid. In adult men a typical prostate is
about three centimeters long and weighs about twenty grams. It is
located in the pelvis, under the urinary bladder and in front of the
rectum. The prostate surrounds part of the urethra, the tube that
carries urine from the bladder during urination and semen during
ejaculation. Because of its location, prostate diseases often affect
urination, ejaculation, or defecation. The prostate contains many small
glands which make about twenty percent of the fluid comprising semen.
In prostate cancer the cells of these prostate glands mutate into cancer
cells. The prostate glands require male hormones, known as androgens, to
work properly. Androgens include testosterone, which is made in the
testes; dehydroepiandrosterone, made in the adrenal glands; and
dihydrotestosterone, made in the prostate itself. Androgens are also
responsible for secondary sex characteristics such as facial hair and
increased muscle mass.
Prostatitis is any form of inflammation of the
prostate gland. Because women do not have a prostate gland, it is a
condition only found in men, although women do have microscopic
paraurethral Skene's glands connected to the distal third of the urethra
in the prevaginal space that are homologous to the prostate, and may
A prostatitis diagnosis is assigned at 8% of all
urologist and 1% of all primary care physician visits in the USA.
The term prostatitis refers in its strictest
sense to histological (microscopic) inflammation of the tissue of the
prostate gland, although historically the term has loosely been used as
a rubric to describe a set of quite different conditions. To try to
remedy this, the NIH devised a new classification system in 1999.
According to the 1999 National Institute of
Health (NIH) Classification, there are four categories of prostatitis:
|| Category I:
|| Acute prostatitis (bacterial)
|| Category II:
|| Chronic bacterial prostatitis
|| Category III:
|| Chronic prostatitis/chronic
pelvic pain syndrome (CP/CPPS), Pelvic Myoneuropathy
Subdivisions of IIIa (inflammatory) and IIIb
(non-inflammatory) exist based on levels of pus cells in expressed
prostatic secretions, but these subcategories are of limited use
|| Category IV:
|| Asymptomatic inflammatory
Category I: Acute prostatitis (bacterial)
Signs and symptoms
Men with this disease often have chills, fever,
pain in the lower back and genital area, urinary frequency and urgency
often at night, burning or painful urination, body aches, and a
demonstrable infection of the urinary tract, as evidenced by white blood
cells and bacteria in the urine. There may be discharge from the penis.
Acute prostatitis is relatively easy to diagnose
due to its symptoms that suggest infection. Common bacteria are E. Coli,
Klebsiella, Proteus, Pseudomonas, Enterobacter, Enterococcus, Serratia,
and Staphylococcus aureus. This can be a medical emergency in some
patients and hospitalization with intravenous antibiotics may be
required. A full blood count reveals increased white blood cells. Sepsis
from prostatitis is very rare, but may occur in immunocompromised
patients; high fever and malaise generally prompt blood cultures, which
are often positive in sepsis.
Antibiotics are the first line of treatment in
acute prostatitis (Cat. I). Antibiotics usually resolve acute
prostatitis infections in a very short period of time. Appropriate
antibiotics should be used, based on the microbe causing the infection.
Some antibiotics have very poor penetration of the prostatic capsule,
others, such as Ciprofloxacin, penetrate well. Severely ill patients may
need hospitalization, while nontoxic patients can be treated at home
with bed rest, analgesics, stool softeners, and hydration.
Full recovery without sequelae is usual.
Category II: Chronic bacterial prostatitis
Signs and symptoms
Chronic bacterial prostatitis is a relatively
rare condition (<5% of patients with prostate-related non-BPH LUTS)
that usually presents with an intermittent UTI-type picture and that is
defined as recurrent urinary tract infections in men originating from a
chronic infection in the prostate. Dr. Weidner, Professor of Medicine,
Department of Urology, University of Giessen, has stated: "In
studies of 656 men, we seldom found chronic bacterial prostatitis. It is
truly a rare disease. Most of those were E-coli." Symptoms may be
completely absent until there is also bladder infection, and the most
troublesome problem is usually recurrent cystitis.
In chronic bacterial prostatitis there are
bacteria in the prostate but usually no symptoms. The prostate infection
is diagnosed by culturing urine as well as prostate fluid (expressed
prostatic secretions or EPS) which are obtained by the doctor doing a
rectal exam and putting pressure on the prostate. If no fluid is
recovered after this prostatic massage, a post massage urine should also
contain any prostatic bacteria. Prostate specific antigen levels may be
elevated, although there is no malignancy.
Treatment requires prolonged courses (4-8 weeks)
of antibiotics that penetrate the prostate well (?-lactams and
nitrofurantoin are ineffective). These include quinolones (ciprofloxacin,
levofloxacin), sulfas (Bactrim, Septra) and macrolides (erythromycin,
clarithromycin). Persistent infections may be helped in 80% of patients
by the use of alpha blockers (tamsulosin (Flomax), alfuzosin), or long
term low dose antibiotic therapy. Recurrent infections may be caused by
inefficient urination (benign prostatic hypertrophy, neurogenic
bladder), prostatic stones or a structural abnormality that acts as a
reservoir for infection.
The addition of prostate massage to courses of
antibiotics was previously proposed as being beneficial. It is though
not without some risk, and has not been shown in more recent trials to
improve outcome compared to antibiotics alone.
Over time, the relapse rate is high, exceeding
Category III: CP/CPPS, pelvic myoneuropathy
Signs and symptoms
In chronic prostatitis/chronic pelvic pain
syndrome (CP/CPPS) there is pelvic pain of unknown cause, lasting longer
than 6 months, as the key symptom. Symptoms may wax and wane. Pain can
range from mild discomfort to debilitating. Pain may radiate to back and
rectum, making sitting difficult. Dysuria, arthralgia, myalgia,
unexplained fatigue, abdominal pain, and frequency may all be present.
Frequent urination and increased urgency may suggest interstitial
cystitis (inflammation centred in bladder rather than prostate).
Ejaculation may be painful, as the prostate contracts during emission of
semen, although nerve- and muscle-mediated post-ejaculatory pain is more
common, and a classic sign of CP/CPPS. Some patients report low libido,
sexual dysfunction and erectile difficulties. Pain after ejaculation is
a very specific complaint that distinguishes CP/CPPS from men with BPH
or normal men.
Theories of Etiology
Theories behind the disease include autoimmunity,
for which there is scant evidence, neurogenic inflammation and
myofascial pain syndrome. In the latter two categories, dysregulation of
the local nervous system due to past traumatic experiences or an anxious
disposition and chronic albeit unconscious pelvic tensing lead to
inflammation that is mediated by substances released by nerve cells
(such as substance P). The prostate (and other areas of the
genitourinary tract: bladder, urethra, testicles) can become inflamed by
the action of the chronically activated pelvic nerves on the mast cells
at the end of the nerve pathways. Similar stress-induced genitourinary
inflammation has been shown experimentally in other mammals.
Prostatitis researcher Dr Anthony Schaeffer
commented in a 2003 editorial of The Journal of Urology that: "It
is well recognized that even if pathogenic bacteria are present in the
prostate, as in men with established chronic bacterial prostatitis, they
do not cause chronic pelvic pain unless acute urinary tract infection
develops. Taken together, these data suggest that bacteria do not have a
significant role in the development of the chronic pelvic pain syndrome.
The clinical observation that antimicrobial therapy reduces
symptomatology in men with chronic pelvic pain syndrome is being tested
in a double-blinded NIH controlled study. Since antimicrobials may have
anti-inflammatory activity, it is possible that these drugs may benefit
the patient by reducing inflammation rather than eradicating
A year after making that statement, Dr Schaeffer
and his colleagues published studies showing that antibiotics are
essentially useless for CP/CPPS.
The bacterial infection theory that for so long
had held sway in this field was again shown to be unimportant in another
2003 study from the University of Washington team led by Dr Lee and
Professor Richard Berger. The study found that one third of both normal
men and patients had equal counts of similar bacteria colonizing their
Since the publication of these studies, the focus
has shifted from infection to neuromuscular and psychological etiologies
for chronic prostatitis .
* Possible role of unculturable bacteria in CPPS:
There have been some questions regarding the role of unculturable/ultra-fastidious
organisms in prostatitis. Although a team led by Keith Jarvi reported
the isolation of unusual bacteria at the American Urological
Association's annual meeting in 2001, it was not published in any
urology journals, a sign that the paper did not withstand the peer
review process. An item about the study was published in Urology Times, a newsletter for urologists. However, subsequent careful PCR
studies failed to replicate these findings, and medical researchers are
now in general agreement that CPPS is not caused by active bacterial
* Non-bacterial prostatitis as a form of
interstitial cystitis (IC): Some researchers have suggested that
non-bacterial prostatitis is a form of interstitial cystitis. A large
multicenter prospective randomized controlled study showed that Elmiron
was slightly better than placebo in treating the symptoms of chronic
prostatitis. Other therapies shown more effective than Elmiron in
treating interstitial cystitis, such as quercetin and Elavil (amitriptyline),
can help with chronic prostatitis.
There are no definitive diagnostic tests for CP/CPPS.
This is a poorly understood disorder, even though it accounts for
90%-95% of prostatitis diagnoses. It is found in men of any age,
with the peak onset in the early 30s. CP/CPPS may be inflammatory
(category IIIa) or non-inflammatory (category IIIb). In the inflammatory
form, urine, semen, and other fluids from the prostate contain pus cells
(dead white blood cells or WBCs), whereas in the non-inflammatory form
no pus cells are present. Recent studies have questioned the distinction
between categories IIIa and IIIb, since both categories show evidence of
inflammation if pus cells are ignored and other more subtle signs of
inflammation, like cytokines, are measured. In 2006, Chinese researchers
found that men with categories IIIa and IIIb both had significantly and
similarly raised levels of anti-inflammatory cytokine TGF and
pro-inflammatory cytokine IFN in their expressed prostatic secretions
when compared with controls; therefore measurement of these cytokines
could be used to diagnose category III prostatitis.
Normal men have slightly more bacteria in their
semen than men with chronic prostatitis/pelvic myoneuropathy. The
traditional Stamey 4-glass test is invalid for diagnosis of this
disorder, and inflammation cannot be localized to any particular area of
the lower GU tract.
Men with CP/CPPS are more likely than the general
population to suffer from Chronic Fatigue Syndrome (CFS), and
Irritable Bowel Syndrome (IBS). Prostate specific antigen levels may be
elevated, although there is no malignancy.
Experimental tests that could be useful in the
future include tests to measure semen and prostate fluid cytokine
levels. Various studies have shown increases in markers for inflammation
such as elevated levels of cytokines, myeloperoxidase, and chemokines.
Physical and psychological therapy
For chronic nonbacterial prostatitis (Cat III),
also known as pelvic myoneuropathy or CP/CPPS, which makes up the
majority of men diagnosed with "prostatitis", a treatment
called the Stanford Protocol, developed by Stanford University
Professor of Urology Rodney Anderson and psychologist David Wise in
1996, has recently been published. This is a combination of medication
(using tricyclic antidepressants and benzodiazepines), psychological
therapy (paradoxical relaxation, an advancement and adaptation,
specifically for pelvic pain, of a type of progressive relaxation
technique developed by Edmund Jacobson during the early 20th century),
and physical therapy (trigger point release therapy on pelvic floor and
abdominal muscles, and also yoga-type exercises with the aim of relaxing
pelvic floor and abdominal muscles). While these studies are
encouraging, definitive proof of efficacy would require a randomized,
sham controlled, blinded study, which is not as easy to do with physical
therapy as with drug therapy.
Cat. III prostatitis may have no initial trigger
other than anxiety, often with an element of Obsessive Compulsive
Disorder or other anxiety-spectrum problem. This is theorized to leave
the pelvic area in a sensitized condition resulting in a loop of muscle
tension and heightened neurological feedback (neural wind-up). Current
protocols largely focus on stretches to release overtensed muscles in
the pelvic or anal area (commonly referred to as trigger points),
physical therapy to the area, and progressive relaxation therapy to
reduce causative stress. Biofeedback physical therapy to relearn how to
control pelvic floor muscles may be useful.
Aerobic exercise can help those sufferers who are
not also suffering from Chronic Fatigue Syndrome (CFS) or whose symptoms
are not exacerbated by exercise.
Anecdotal evidence suggests that food allergies
and intolerances may have a role in exacerbating CP/CPPS, perhaps
through mast cell mediated mechanisms. Specifically patients with gluten
intolerance or celiac disease report severe symptom flares after
sustained gluten ingestion. Patients may therefore find an exclusion
diet helpful in lessening symptoms by identifying problem foods. Studies
are lacking in this area.
There is a substantial list of medications used
to treat this disorder.
Alpha blockers (tamsulosin, alfuzosin) are
moderately helpful for many men with CPPS; duration of therapy needs to
be at least 3 months.
Quercetin has shown effective in a randomized,
placebo-controlled trial in chronic prostatitis using 500 mg twice a day
for 4 weeks. Subsequent studies showed that quercetin, a mast cell
inhibitor, reduces inflammation and oxidative stress in the prostate.
Pollen extract (Cernilton) has also been shown
effective in randomized placebo controlled trials.
Commonly used therapies that have not been
properly evaluated in clinical trials are dietary modification,
gabapentin, and amitriptyline. Therapies shown to be ineffective by
randomized placebo/sham controlled trials: levaquin (antibiotics), alpha
blockers for 6 weeks or less, transurethral needle ablation of the
At least one study suggests that multi-modal
therapy (aimed at different pathways such as inflammation and
neuromuscular dysfunction simultaneously) is better long term than
In recent years the prognosis for CP/CPPS has
improved greatly with the advent of multimodal treatment, phytotherapy
and protocols aimed at quieting the pelvic nerves through myofascial
trigger point release and anxiety control.
Category IV: Asymptomatic inflammatory
Signs and symptoms
These patients have no history of genitourinary
pain complaints, but leukocytosis or bacteria have been noted during
evaluation for other conditions.
Diagnosis is through tests of semen, EPS or urine
that reveal inflammation in the absence of symptoms.
No treatment required. It is standard practice
for men with infertility and category IV prostatitis to be given a trial
of antibiotics and/or anti-inflammatories however evidence for efficacy
are weak. Since signs of asymptomatic prostatic inflammation may
sometimes be associated with prostate cancer, this can be addressed by
tests that assess the ratio of free-to-total PSA. The results of these
tests were significantly different in prostate cancer and category IV
prostatitis in one study.
Benign Prostatic Hyperplasia
Benign prostatic hyperplasia (BPH) also known as
Benign prostatic hypertrophy or Benign enlargement of the prostate (BEP)
refers to the increase in size of the prostate in middle-aged and
elderly men. To be accurate, the process is one of hyperplasia rather
than hypertrophy, but the nomenclature is often interchangeable, even
amongst urologists. In BPH, the prostate grows larger and presses
against the urethra and bladder, interfering with the normal flow of
urine. It leads to symptoms of urinary hesitancy, frequent urination,
increased risk of urinary tract infections and urinary retention. There
is little correlation between BPH symptoms and the presence of prostate
Urinary symptoms of hesitancy, sensation of
incomplete voiding and frequently passing small amounts of urine are all
suggestive of BPH in middle-aged and elderly men. Due to the incomplete
voiding, there is stasis of bacteria in the bladder residue and an
increased risk of urinary tract infections.
Incomplete voiding (emptying) of the bladder
caused by BPH also provides suitable conditions for the development of
urinary bladder stones. These are formed from the crystallization of
waste salts in the urine. Symptoms of bladder stone include blood in the
urine and moderate to severe pain which can feel as though it is located
in the penis, or around the anus, as well as the bladder. As the stone
(which is often spikey) develops in size it produces increased pain and
gradual reduction in mobility.
A small proportion presents with urinary
retention, in which inadequate amounts of urine are passed and the
bladder distends greatly. Untreated, this leads to a decrease in renal
function and hydronephrosis (obstructive uropathy).
Androgens (testosterone and related hormones) are
considered to play a permissive role in BPH by most experts. This means
that androgens have to be present for BPH to occur, but do not
necessarily directly cause the condition. This is supported by the fact
that castrated boys do not develop BPH when they age, unlike intact men.
Additionally, administering exogenous testosterone is not associated
with a significant increase in the risk of BPH symptoms.
Dihydrotestosterone (DHT), a metabolite of testosterone is a critical
mediator of prostatic growth. DHT is synthesized in the prostate from
DHT is localized principally in the stromal
cells. Once synthesized, DHT can act in an autocrine fashion on the
stromal cells or in paracrine fashion by diffusing into nearby
epithelial cells. In both of these cell types, DHT binds to nuclear
androgen receptors and signals the transcription of growth factors that
are mitogenic to the epithelial and stromal cells. The importance of DHT
in causing nodular hyperplasia is supported by clinical observations in
which an inhibitor of 5?-reductase is given to men with this condition.
Therapy with 5?-reductase inhibitor markedly reduces the DHT content of
the prostate and in turn reduces prostate volume and, in many cases, BPH
There is growing evidence that estrogens play a
role in the etiology of BPH. This is based on the fact that BPH occurs
when men generally have elevated estrogen levels and relatively reduced
free testosterone levels, and when prostate tissue becomes more
sensitive to estrogens and less responsive to DHT. Cells taken from the
prostates of men who have BPH have been shown to grow in response to
high estradiol levels with low androgens present.
On a microscopic level, BPH can be seen in the
vast majority of men as they age, particularly over the age of 70 years,
around the world. However, rates of clinically significant, symptomatic
BPH vary dramatically depending on lifestyle. Men who lead a western
lifestyle have a much higher incidence of symptomatic BPH than men who
lead a traditional or rural lifestyle. This is confirmed by research in
China showing that men in rural areas have very low rates of clinical
BPH, while men living in cities adopting a western lifestyle have a
skyrocketing incidence of this condition, though it is still below rates
seen in the West.
Much work remains to be done to completely
clarify the causes of BPH.
Rectal examination (palpation of the prostate
through the rectum) may reveal a markedly enlarged prostate. It is
dependent on the skills of the doctor.
Often, blood tests are performed to rule out
prostatic malignancy: elevated prostate specific antigen (PSA) levels
suggest prostate cancer. It has to be borne in mind that rectal
examination can increase PSA levels in patients without malignancy.
Ultrasound examination of the testicles, prostate
and kidneys is often performed, again to rule out malignancy and
More than half of the men in the United States
between the ages of 60 and 70 and as many as 90% between the ages of 70
and 90 have symptoms of BPH. For some men, the symptoms may be severe
enough to require treatment.
Alpha blockers (adrenergic receptor antagonists)
(such as doxazosin, prazosin, alfuzosin and tamsulosin) and
certain antiandrogens such as the reductase inhibitors (finasteride
and dutasteride) are used, often together, in suppressing the symptoms.
Alpha-blockers relax smooth muscle in the prostate and bladder neck
decreasing the degree of blockage of urine flow. Alpha-blockers may
cause ejaculation back into the bladder (retrograde ejaculation). This
is not harmful.
There is also extensive evidence of the efficacy
of Serenoa repens (saw palmetto) fruit extracts in alleviating
mild-to-moderate BPH symptoms. A systematic review of evidence found
comparable efficacy to finasteride. Other herbal
medicines that have solid research support in systematic reviews include
beta-sitosterol from Hypoxis rooperi (African star grass) and Prunus
africanum (pygeum) bark, while there is less substantial support for the
efficacy of Cucurbita pepo (pumpkin) seed and Urtica dioica (stinging
nettle) root. At least one double-blind trial has
also supported the efficacy of rye flower pollen.
Sildenafil shows some symptomatic relief,
suggesting a possible common etiology with erectile disfunction.
If medical treatment fails, transurethral
resection of prostate (TURP) surgery may need to be performed. This
involves removing (part of) the prostate through the urethra. There are
also a number of new methods for reducing the size of an enlarged
prostate, some of which have not been around long enough to fully
establish their safety or side effects. These include various methods to
destroy or remove part of the excess tissue while trying to avoid
damaging what's left. Transurethral electrovaporization of the prostate
(TVP), laser TURP, visual laser ablation (VLAP), TransUrethral Microwave
ThermoTherapy (TUMT), TransUrethral Needle Ablation (TUNA), ethanol
injection, and others are studied as alternatives.
Newer techniques involving lasers in urology have
emerged in the last 5-10 years. Starting with the VLAP technique
involving the ND:YAG laser with contact on the prostatic tissue. A
similar technology called Photoselective Vaporization of the Prostate (PVP)
with the GreenLight (KTP) laser have emerged very recently. This
procedure involves a high powered 80 Watt KTP laser with a 550
micrometre laser fiber inserted into the prostate. This fiber has an
internal reflection with a 70 degree deflecting angle. It is used to
vaporize the tissue to the prostatic capsule. KTP lasers target
haemoglobin as the chromophore and have typically have a penetration
depth of 2.0mm (four times deeper than holmium).
Another procedure termed Holmium Laser Ablation
of the Prostate(HoLAP) has also been gaining acceptance around the
world. Like KTP the delivery device for HoLAP procedures is a 550um
disposable side-firing fiber that directs the beam from a high powered
100 Watt laser at a 70degree from the fiber axis. The holmium wavelength
is 2,140nm, which falls within the infrared portion of the spectrum and
is invisible to the naked eye. Where KTP relies on haemoglobin as a
chromophore, water within the target tissue is the chromophore for
Holmium lasers. The pentration depth of Holmium lasers is <0.5mm
avoiding complications associated with tissue necrosis often found with
the deeper penetration and lower peak powers of KTP.
Both wavelengths, KTP and Holmium, ablate
approximately one to two grams of tissue per minute.
Cystitis is the inflammation of the bladder. The
condition primarily affects women, but can affect either sex and all age
There are several types of cystitis:
|| bacterial cystitis, the most common type, which
is most often caused by coliform bacteria being transferred from the
bowel through the urethra into the bladder
|| interstitial cystitis, which is painful,
difficult to diagnose, and does not involve foreign organisms
|| hemorrhagic cystitis
Causes, incidence and risk factors:
Cystitis occurs when the normally sterile lower
urinary tract (urethra and bladder) is infected by bacteria and becomes
irritated and inflamed. It is very common.
The condition frequently affects sexually active
women ages 20 to 50 but may also occur in those who are not sexually
active or in young girls. Older adults are also at high risk for
developing cystitis, with the incidence in the elderly being much higher
than in younger people.
Cystitis is rare in males. Females are more prone
to the development of cystitis because of their relatively shorter
urethra -- bacteria do not have to travel as far to enter the bladder --
and because of the relatively short distance between the opening of the
urethra and the anus.
More than 85% of cases of cystitis are caused by
Escherichia coli, a bacterium found in the lower gastrointestinal tract.
Sexual intercourse may increase the risk of cystitis because bacteria
can be introduced into the bladder through the urethra during sexual
activity. Once bacteria enter the bladder, they normally are removed
through urination. When bacteria multiply faster than they are removed
by urination, infection results.
Risks for cystitis include obstruction of the
bladder or urethra with resultant stagnation of urine, insertion of
instruments into the urinary tract (such as catheterization or
cystoscopy), pregnancy, diabetes, HIV, and a history of analgesic
nephropathy or reflux nephropathy.
The elderly of both sexes are at increased risk
for developing cystitis due to incomplete emptying of the bladder
associated with such conditions as benign prostatic hyperplasia (BPH),
prostatitis and urethral strictures. Also, lack of adequate fluids,
bowel incontinence, immobility or decreased mobility and placement in a
nursing home, all put people at increased risk for cystitis.
|| Pressure in the lower pelvis
|| Painful urination (dysuria)
|| Frequent or urgent need to urinate
|| Need to urinate at night (nocturia)
|| Abnormal urine color (cloudy)
|| Blood in the urine (hematuria)
|| Foul or strong urine odor
Signs and Tests
|| A urinalysis commonly reveals white blood cells
(WBCs) or red blood cells (RBCs).
|| A urine culture (clean catch) or catheterized
urine specimen may be performed to determine the type of bacteria in the
urine and the appropriate antibiotic for treatment.
Because of the risk of the infection spreading to
the kidneys (complicated UTI) and due to the high complication rate in
the elderly population and in diabetics, prompt treatment is almost
Antibiotics are used to control the bacterial
infection. It is vital that you finish the entire course of prescribed
antibiotics. Commonly used antibiotics include:
|| Ciprofloxacin or levofloxacin
The choice of antibiotic should preferably be
guided by the result of urine culture.
Chronic or recurrent UTI should be treated
thoroughly because of the chance of kidney infection (pyelonephritis).
Antibiotics control the bacterial infection. They may be required for
long periods of time. Prophylactic low-dose antibiotics are sometimes
recommended after acute symptoms have subsided.
Pyridium may be used to reduce the burning and
urgency associated with cystitis. In addition, common substances that
increase acid in the urine, such as ascorbic acid or cranberry juice,
may be recommended to decrease the concentration of bacteria in the
Follow-up may include urine cultures to ensure
that bacteria are no longer present in the bladder.
Most cases of cystitis are uncomfortable but
disappear without complication after treatment.
|| Chronic or recurrent urinary tract infection
|| Complicated UTI (pyelonephritis)
|| Acute renal failure
Keeping the genital area clean and remembering to
wipe from front to back may reduce the chance of introducing bacteria
from the rectal area to the urethra.
Increasing the intake of fluids may allow
frequent urination to flush the bacteria from the bladder. Urinating
immediately after sexual intercourse may help eliminate any bacteria
that may have been introduced during intercourse. Refraining from
urinating for long periods of time may allow bacteria time to multiply,
so frequent urinating may reduce risk of cystitis in those who are prone
to urinary tract infections.
Drinking cranberry juice prevents certain types
of bacteria from attaching to the wall of the bladder and may lessen the
chance of infection.
Prostate cancer is a disease in which cancer
develops in the prostate, a gland in the male reproductive system.
Cancer occurs when cells of the prostate mutate and begin to multiply
out of control. These cells may spread (metastasize) from the prostate
to other parts of the body, especially the bones and lymph nodes.
Prostate cancer may cause pain, difficulty in urinating, erectile
dysfunction and other symptoms.
Rates of prostate cancer vary widely across the
world. Although the rates vary widely between countries, it is least
common in South and East Asia, more common in Europe, and most common in
the United States. According to the American Cancer Society, prostate
cancer is least common among Asian men and most common among black men
with figures for European men in-between . However, these high rates may
be affected by increasing rates of detection .
Prostate cancer develops most frequently in men
over fifty. This cancer can occur only in men, as the prostate is
exclusively of the male reproductive tract. It is the most common type
of cancer in men in the United States, where it is responsible for more
male deaths than any other cancer, except lung cancer. However, many men
who develop prostate cancer never have symptoms, undergo no therapy, and
eventually die of other causes. Many factors, including genetics and
diet, have been implicated in the development of prostate cancer.
Prostate cancer is most often discovered by
physical examination or by screening blood tests, such as the PSA
(prostate specific antigen) test. There is some current concern about
the accuracy of the PSA test and its usefulness. Suspected prostate
cancer is typically confirmed by removing a piece of the prostate
(biopsy) and examining it under a microscope. Further tests, such as
X-rays and bone scans, may be performed to determine whether prostate
cancer has spread.
Prostate cancer can be treated with surgery,
radiation therapy, hormone therapy, occasionally chemotherapy, or some
combination of these. The age and underlying health of the man as well
as the extent of spread, appearance under the microscope, and response
of the cancer to initial treatment are important in determining the
outcome of the disease. Since prostate cancer is a disease of older men,
many will die of other causes before the prostate cancer can spread or
cause symptoms. This makes treatment selection difficult. The
decision whether or not to treat localized prostate cancer (a tumor that
is contained within the prostate) with curative intent is a patient
trade-off between the expected beneficial and harmful effects in terms
of patient survival and quality of life.
When normal cells
are damaged beyond
repair, they are eliminated by apoptosis.
Cancer cells avoid apoptosis and continue
to multiply in an unregulated manner.
Early prostate cancer usually causes no symptoms.
Often it is diagnosed during the workup for an elevated PSA noticed
during a routine checkup. Sometimes, however, prostate cancer does cause
symptoms, often similar to those of diseases such as benign prostatic
hypertrophy. These include frequent urination, increased urination at
night, difficulty starting and maintaining a steady stream of urine,
blood in the urine, and painful urination. Prostate cancer may also
cause problems with sexual function, such as difficulty achieving
erection or painful ejaculation
Advanced prostate cancer may cause additional
symptoms as the disease spreads to other parts of the body. The most
common symptom is bone pain, often in the vertebrae (bones of the
spine), pelvis or ribs, from cancer which has spread to these bones.
Prostate cancer in the spine can also compress the spinal cord, causing
leg weakness and urinary and fecal incontinence.
Prostate cancer is classified as an adenocarcinoma, or glandular cancer, that begins when normal
semen-secreting prostate gland cells mutate into cancer cells. The
region of prostate gland where the adenocarcinoma is most common is the
peripheral zone. Initially, small clumps of cancer cells remain confined
to otherwise normal prostate glands, a condition known as carcinoma in
situ or prostatic intraepithelial neoplasia (PIN). Although there is no
proof that PIN is a cancer precursor, it is closely associated with
cancer. Over time these cancer cells begin to multiply and spread to the
surrounding prostate tissue (the stroma) forming a tumor. Eventually,
the tumor may grow large enough to invade nearby organs such as the
seminal vesicles or the rectum, or the tumor cells may develop the
ability to travel in the bloodstream and lymphatic system. Prostate
cancer is considered a malignant tumor because it is a mass of cells
which can invade other parts of the body. This invasion of other organs
is called metastasis. Prostate cancer most commonly metastasizes to the
bones, lymph nodes, rectum, and bladder.
The specific causes of prostate cancer remain
unknown A man's risk of developing prostate cancer is related to his
age, genetics, race, diet, lifestyle, medications, and other factors.
The primary risk factor is age. Prostate cancer is uncommon in men less
than 45, but becomes more common with advancing age. The average age at
the time of diagnosis is 70. However, many men never know they have
prostate cancer. Autopsy studies of Chinese, German, Israeli, Jamaican,
Swedish, and Ugandan men who died of other causes have found prostate
cancer in thirty percent of men in their 50s, and in eighty percent of
men in their 70s. In the year 2005 in the United States, there were an
estimated 230,000 new cases of prostate cancer and 30,000 deaths due to
A man's genetic background contributes to his
risk of developing prostate cancer. This is suggested by an increased
incidence of prostate cancer found in certain racial groups, in
identical twins of men with prostate cancer, and in men with certain
genes. In the United States, prostate cancer more commonly affects black
men than white or Hispanic men, and is also more deadly in black men.
Men who have a brother or father with prostate cancer have twice the
usual risk of developing prostate cancer. Studies of twins in
Scandinavia suggest that forty percent of prostate cancer risk can be
explained by inherited factors. However, no single gene is responsible
for prostate cancer; many different genes have been implicated. Two
genes (BRCA1 and BRCA2) that are important risk factors for ovarian
cancer and breast cancer in women have also been implicated in prostate
Dietary amounts of certain foods, vitamins, and
minerals can contribute to prostate cancer risk. Men with higher serum
levels of the short-chain fatty acid linolenic acid have higher
rates of prostate cancer. However, the same series of studies showed
that men with elevated levels of long-chain (EPA and DHA) had
lowered incidence. A long-term study reports that "blood levels of
trans fatty acids, in particular trans fats resulting from the
hydrogenation of vegetable oils, are associated with an increased
prostate cancer risk." Other dietary factors that may increase
prostate cancer risk include low intake of vitamin E (Vitamin E is found
in green, leafy vegetables), lycopene (found in tomatoes), omega-3 fatty
acids (found in fatty fishes like salmon), and the mineral selenium.
Lower blood levels of vitamin D also may increase the risk of developing
prostate cancer. This may be linked to lower exposure to ultraviolet
(UV) light, since UV light exposure can increase vitamin D in the body.
Green tea may also be protective (due to its polyphenol content), though
the data are mixed.
There are also some links between prostate cancer
and medications, medical procedures, and medical conditions. Daily use
of anti-inflammatory medicines such as aspirin, ibuprofen, or naproxen
may decrease prostate cancer risk. Use of the cholesterol-lowering drugs
known as the statins may also decrease prostate cancer risk.
Sterilization by vasectomy may increase the risk of prostate cancer,
though there are conflicting data. More frequent ejaculation also may
decrease a man's risk of prostate cancer. One study showed that men who
ejaculated five times a week in their 20s had a decreased rate of
prostate cancer, though others have shown no benefit.
Infection or inflammation of the prostate (prostatitis)
may increase the chance for prostate cancer. In particular, infection
with the sexually transmitted infections chlamydia, gonorrhea, or
syphilis seems to increase risk. Finally, obesity and elevated blood
levels of testosterone may increase the risk for prostate cancer.
Prostate cancer risk can be decreased by
modifying known risk factors for prostate cancer, such as decreasing
intake of animal fat. Several medications and vitamins may also help
prevent prostate cancer. Two dietary supplements, vitamin E and
selenium, may help prevent prostate cancer when taken daily. Estrogens
from soybeans and other plant sources (called phytoestrogens) may also
help prevent prostate cancer. The selective estrogen receptor modulator
drug toremifene has shown promise in early trials. Two medications which
block the conversion of testosterone to dihydrotestosterone, finasteride
and dutasteride, have also shown some promise. As of 2006 the use of
these medications for primary prevention is still in the testing phase,
and they are not widely used for this purpose.
Prostate cancer screening
Prostate cancer screening is an attempt to find
unsuspected cancers. Screening tests may lead to more specific follow-up
tests such as a biopsy, where small pieces of the prostate are removed
for closer study. As of 2006 prostate cancer screening options include
the digital rectal exam and the prostate specific antigen (PSA) blood
test. Screening for prostate cancer is controversial because it is not
clear if the benefits of screening outweigh the risks of follow-up
diagnostic tests and cancer treatments.
Prostate cancer is a slow-growing cancer, very
common among older men. In fact, most prostate cancers never grow to the
point where they cause symptoms, and most men with prostate cancer die
of other causes before prostate cancer has an impact on their lives. The
PSA screening test may detect these small cancers that would never
become life threatening. Doing the PSA test in these men may lead to
overdiagnosis, including additional testing and treatment. Follow-up
tests, such as prostate biopsy, may cause pain, bleeding and infection.
Prostate cancer treatments may cause urinary incontinence and erectile
dysfunction. Therefore, it is essential that the risks and benefits of
diagnostic procedures and treatment be carefully considered before PSA
Prostate cancer screening generally begins after
age fifty, but may be offered earlier in black men or men with a strong
family history of prostate cancer. Although there is no officially
recommended cutoff, many health care providers stop monitoring PSA in
men who are older than 75 years old because of concern that prostate
cancer therapy may do more harm than good as age progresses and life
Digital rectal examination
Digital rectal examination (DRE) is a procedure
where the examiner inserts a gloved, lubricated finger into the rectum
to check the size, shape, and texture of the prostate. Areas which are
irregular, hard or lumpy need further evaluation, since they may contain
cancer. Although the DRE only evaluates the back of the prostate, 85% of
prostate cancers arise in this part of the prostate. Prostate cancer
which can be felt on DRE is generally more advanced. The use of DRE has
never been shown to prevent prostate cancer deaths when used as the only
Prostate specific antigen
The PSA test measures the blood level of
prostate-specific antigen, an enzyme produced by the prostate.
Specifically, PSA is a serine protease similar to kallikrein. Its normal
function is to liquify gelatinous semen after ejaculation, allowing
spermatazoa to more easily "swim" through the uterine cervix.
PSA levels under 4 ng/mL (nanograms per
milliliter) are generally considered normal, while levels over 4 ng/mL
are considered abnormal (although in men over 65 levels up to 6.5 ng/mL
may be acceptable, depending upon each laboratory's reference ranges).
PSA levels between 4 and 10 ng/mL indicate a risk of prostate cancer
higher than normal, but the risk does not seem to rise within this
six-point range. When the PSA level is above 10 ng/mL, the association
with cancer becomes stronger. However, PSA is not a perfect test. Some
men with prostate cancer do not have an elevated PSA, and most men with
an elevated PSA do not have prostate cancer.
PSA levels can change for many reasons other than
cancer. Two common causes of high PSA levels are enlargement of the
prostate (benign prostatic hypertrophy (BPH)) and infection in the
prostate (prostatitis). It can also be raised for several weeks after
ejaculation and after catheterization. PSA levels are lowered in men who
use medications used to treat BPH or baldness. These medications,
finasteride (marketed as Proscar or Propecia) and dutasteride (marketed
as Avodart), may decrease the PSA levels by 50% or more.
Several other ways of evaluating the PSA have
been developed to avoid the shortcomings of simple PSA screening. The
use of age-specific reference ranges improves the sensitivity and
specificity of the test. The rate of rise of the PSA over time, called
the PSA velocity, has been used to evaluate men with PSA levels between
4 and 10 ng/ml, but as of 2006, it has not proven to be an effective
screening test. Comparing the PSA level with the size of the
prostate, as measured by ultrasound or magnetic resonance imaging, has
also been studied. This comparison, called PSA density, is both costly
and, as of 2006, has not proven to be an effective screening test.
PSA in the blood may either be free or bound to other proteins.
Measuring the amount of PSA which is free or bound may provide
additional screening information, but as of 2006, questions regarding
the usefulness of these measurements limit their widespread use.
|Normal prostate (A) and prostate cancer (B).
prostate cancer, the regular
glands of the normal prostate are replaced
by irregular glands and clumps of
cells, as seen in these pictures taken
through a microscope.
Confirming the diagnosis
When a man has symptoms of prostate cancer, or a
screening test indicates an increased risk for cancer, more invasive
evaluation is offered. The only test which can fully confirm the
diagnosis of prostate cancer is a biopsy, the removal of small pieces of
the prostate for microscopic examination. However, prior to a biopsy,
several other tools may be used to gather more information about the
prostate and the urinary tract. Cystoscopy shows the urinary tract from
inside the bladder, using a thin, flexible camera tube inserted down the
urethra. Transrectal ultrasonography creates a picture of the prostate
using sound waves from a probe in the rectum.
If cancer is suspected, a biopsy is offered.
During a biopsy a urologist obtains tissue samples from the prostate via
the rectum. A biopsy gun inserts and removes special hollow-core needles
(usually three to six on each side of the prostate) in less than a
second. The tissue samples are then examined under a microscope to
determine whether cancer cells are present, and to evaluate the
microscopic features (or Gleason score) of any cancer found. Prostate
biopsies are routinely done on an outpatient basis and rarely require
hospitalization. Fifty-five percent of men report discomfort during
Currently, an active area of research involves
non-invasive methods of prostate tumor detection. Adenoviruses modified
to transfect tumor cells with harmless yet distinct genes (such as
luciferase) have proven capable of early detection. So far, though, this
area of research has only been tested in animal and LNCaP models.
Prostate cancer staging
An important part of evaluating prostate cancer
is determining the stage, or how far the cancer has spread. Knowing the
stage helps define prognosis and is useful when selecting therapies. The
most common system is the four-stage TNM system (abbreviated from
Tumor/Nodes/Metastases). Its components include the size of the tumor,
the number of involved lymph nodes, and the presence of any other
The most important distinction made by any
staging system is whether or not the cancer is still confined to the
prostate. In the TNM system, clinical T1 and T2 cancers are found only
in the prostate, while T3 and T4 cancers have spread elsewhere. Several
tests can be used to look for evidence of spread. These include computed
tomography to evaluate spread within the pelvis, bone scans to look for
spread to the bones, and endorectal coil magnetic resonance imaging to
closely evaluate the prostatic capsule and the seminal vesicles.
After a prostate biopsy, a pathologist looks at
the samples under a microscope. If cancer is present, the pathologist
reports the grade of the tumor. The grade tells how much the tumor
tissue differs from normal prostate tissue and suggests how fast the
tumor is likely to grow. The Gleason system is used to grade prostate
tumors from 2 to 10, where a Gleason score of 10 indicates the most
abnormalities. The pathologist assigns a number from 1 to 5 for the most
common pattern observed under the microscope, then does the same for the
second most common pattern. The sum of these two numbers is the Gleason
score. The Whitmore-Jewett stage is another method sometimes used.
Proper grading of the tumor is critical, since the grade of the tumor is
one of the major factors used to determine the treatment recommendation
Many prostate cancers are not destined to be
lethal, and most men will ultimately die from causes other than of the
disease. Decisions about treatment type and timing may therefore be
informed by an estimation of the risk that the tumor will ultimately
recur after treatment and/or progress to metastases and mortality.
Several tools are available to help predict outcomes such as pathologic
stage and recurrence after surgery or radiation therapy. Most combine
stage, grade, and PSA level, and some also add the number or percent of
biopsy cores positive, age, and/or other information.
The D’Amico classification stratifies men to
low, intermediate, or high risk based on stage, grade, and PSA. It is
used widely in clinical practice and research settings. The major
downside to the 3-level system is that it does not account for multiple
adverse parameters (e.g., high Gleason score and high PSA) in
The Partin tables predict pathologic outcomes
(margin status, extraprostatic extension, and seminal vesicle invasion)
based on the same 3 variables, and are published as lookup tables.
The Kattan nomograms predict recurrence after
surgery and/or radiation therapy, based on data available either at time
of diagnosis or after surgery. The nomograms can be calculated using
paper graphs, or using software available on a website or for handheld
computers. The Kattan score represents the likelihood of remaining free
of disease at a given time interval following treatment.
The UCSF Cancer of the Prostate Risk Assessment
(CAPRA) score predicts both pathologic status and recurrence after
surgery. It offers comparable accuracy as the Kattan preoperative
nomogram, and can be calculated without paper tables or a calculator.
Points are assigned based on PSA, Grade, stage, age, and percent of
cores positive; the sum yields a 0-10 score, with every 2 points
representing roughly a doubling of risk of recurrence. The CAPRA score
was derived from community-based data in the CaPSURE database.
Treatment for prostate cancer may involve
watchful waiting, surgery, radiation therapy, High Intensity Focused
Ultrasound (HIFU), chemotherapy, cryosurgery, hormonal therapy, or some
combination. Which option is best depends on the stage of the disease,
the Gleason score, and the PSA level. Other important factors are the
man's age, his general health, and his feelings about potential
treatments and their possible side effects. Because all treatments can
have significant side effects, such as erectile dysfunction and urinary
incontinence, treatment discussions often focus on balancing the goals
of therapy with the risks of lifestyle alterations.
If the cancer has spread beyond the prostate,
treatment options significantly change, so most doctors who treat
prostate cancer use a variety of nomograms to predict the probability of
spread. Treatment by watchful waiting, HIFU, radiation therapy,
cryosurgery, and surgery are generally offered to men whose cancer
remains within the prostate. Hormonal therapy and chemotherapy are often
reserved for disease which has spread beyond the prostate. However,
there are exceptions: radiation therapy may be used for some advanced
tumors, and hormonal therapy is used for some early stage tumors.
Cryotherapy, hormonal therapy, and chemotherapy may also be offered if
initial treatment fails and the cancer progresses.
Watchful waiting / Active Surveillance
Watchful waiting, also called "active
surveillance," refers to observation and regular monitoring without
invasive treatment. Watchful waiting is often used when an early stage,
slow-growing prostate cancer is found in an older man. Watchful waiting
may also be suggested when the risks of surgery, radiation therapy, or
hormonal therapy outweigh the possible benefits. Other treatments can be
started if symptoms develop, or if there are signs that the cancer
growth is accelerating (e.g., rapidly rising PSA, increase in Gleason
score on repeat biopsy, etc.). Most men who choose watchful waiting for
early stage tumors eventually have signs of tumor progression, and they
may need to begin treatment within three years. Although men who choose
watchful waiting avoid the risks of surgery and radiation, the risk of
metastasis (spread of the cancer) may be increased. For younger men, a
trial of active surveillance may not mean avoiding treatment altogether,
but may reasonably allow a delay of a few years or more, during which
time the quality of life impact of active treatment can be avoided.
Published data to date suggest that carefully selected men will not miss
a window for cure with this approach. Additional health problems that
develop with advancing age during the observation period can also make
it harder to undergo surgery and radiation therapy.
Surgical removal of the prostate, or
prostatectomy, is a common treatment either for early stage prostate
cancer, or for cancer which has failed to respond to radiation therapy.
The most common type is radical retropubic prostatectomy, when the
surgeon removes the prostate through an abdominal incision. Another type
is radical perineal prostatectomy, when the surgeon removes the prostate
through an incision in the perineum, the skin between the scrotum and
anus. Radical prostatectomy can also be performed laparoscopically,
through a series of small (1cm) incisions in the abdomen, with or
without the assistance of a surgical robot.
Radical prostatectomy is highly effective for
tumors which have not spread beyond the prostate; cure rates depend on
risk factors such as PSA level and Gleason grade. However, it may cause
nerve damage that significantly alters the quality of life of the
prostate cancer survivor. The most common serious complications are loss
of urinary control and impotence. Reported rates of both complications
vary widely depending on how they are assessed, by whom, and how long
after surgery, as well as the setting (e.g., academic series vs.
community-based or population-based data). Although penile sensation and
the ability to achieve orgasm usually remain intact, erection and
ejaculation are often impaired. Medications such as sildenafil (Viagra),
tadalafil (Cialis), or vardenafil (Levitra) may restore some degree of
potency. For most men with organ-confined disease, a more limited
"nerve-sparing" technique may help avoid urinary incontinence
Radical prostatectomy has traditionally been used
alone when the cancer is small. In the event of positive margins or
locally advanced disease found on pathology, adjuvant radiation therapy
may offer improved survival. Surgery may also be offered when a cancer
is not responding to radiation therapy. However, because radiation
therapy causes tissue changes, prostatectomy after radiation has a
higher risk of complications.
Transurethral resection of the prostate, commonly
called a "TURP," is a surgical procedure performed when the
tube from the bladder to the penis (urethra) is blocked by prostate
enlargement. TURP is generally for benign disease and is not meant as
definitive treatment for prostate cancer. During a TURP, a small tube (cystoscope)
is placed into the penis and the blocking prostate is cut away.
In metastatic disease, where cancer has spread
beyond the prostate, removal of the testicles (called orchiectomy) may
be done to decrease testosterone levels and control cancer growth. (See
hormonal therapy, below).
Radiation therapy, also known as radiotherapy,
uses ionizing radiation to kill prostate cancer cells. When absorbed in
tissue, Ionizing radiation such as Gamma and x-rays damage the DNA in
cells, which increases the probability of apoptosis (cell death). Two
different kinds of radiation therapy are used in prostate cancer
treatment: external beam radiation therapy and brachytherapy.
for prostate cancer is administered using "seeds," small
radioactive rods implanted directly into the tumor
radiation therapy for prostate cancer is
delivered by a linear accelerator, such as this one.
External beam radiation therapy uses a linear
accelerator to produce high-energy x-rays which are directed in a beam
towards the prostate. A technique called Intensity Modulated Radiation
Therapy (IMRT) may be used to adjust the radiation beam to conform with
the shape of the tumor, allowing higher doses to be given to the
prostate and seminal vesicles with less damage to the bladder and
rectum. External beam radiation therapy is generally given over several
weeks, with daily visits to a radiation therapy center.
Permanent implant brachytherapy is a popular
treatment choice for patients with low to intermediate risk features, can
be performed on an outpatient basis, and is associated with good 10-year
outcomes with relatively low morbidity. It involves the placement of
about 100 small "seeds" containing radioactive material (such as
iodine-125 or palladium-103) with a needle through the skin of the
perineum directly into the tumor while under spinal or general anesthetic.
These seeds emit lower-energy X-rays which are only able to travel a short
distance. Although the seeds eventually become inert, they remain in the
prostate permanently. The risk of exposure to others from men with
implanted seeds is generally accepted to be insignificant.
Radiation therapy is commonly used in prostate
cancer treatment. It may be used instead of surgery for early cancers, and
it may also be used in advanced stages of prostate cancer to treat painful
bone metastases. Radiation treatments also can be combined with hormonal
therapy for intermediate risk disease, when radiation therapy alone is
less likely to cure the cancer. Some radiation oncologists combine
external beam radiation and brachytherapy for intermediate to high risk
situations. One study found that the combination of six months of androgen
suppressive therapy combined with external beam radiation had improved
survival compared to radiation alone in patients with localized prostate
cancer. Others use a "triple modality" combination of
external beam radiation therapy, brachytherapy, and hormonal therapy.
Less common applications for radiotherapy are when
cancer is compressing the spinal cord, or sometimes after surgery, such as
when cancer is found in the seminal vesicles, in the lymph nodes, outside
the prostate capsule, or at the margins of the biopsy.
Radiation therapy is often offered to men whose
medical problems make surgery more risky. Radiation therapy appears to
cure small tumors that are confined to the prostate just about as well as
surgery. However, as of 2006 some issues remain unresolved, such as
whether radiation should be given to the rest of the pelvis, how much the
absorbed dose should be, and whether hormonal therapy should be given at
the same time.
Side effects of radiation therapy might occur after
a few weeks into treatment. Both types of radiation therapy may cause
diarrhea and rectal bleeding due to radiation proctitis, as well as
urinary incontinence and impotence. Symptoms tend to improve over time.
Men who have undergone external beam radiation therapy will have a higher
risk of later developing colon cancer and bladder cancer.
Cryosurgery is another method of treating prostate
cancer. It is less invasive than radical prostatectomy, and general
anesthesia is less commonly used. Under ultrasound guidance, metal rods
are inserted through the skin of the perineum into the prostate. Highly
purified Argon gas is used to cool the rods, freezing the surrounding
tissue at -196 °C (-320 °F). As the water within the prostate cells
freeze, the cells die. The urethra is protected from freezing by a
catheter filled with warm liquid. Cryosurgery generally causes fewer
problems with urinary control than other treatments, but impotence occurs
up to ninety percent of the time. When used as the initial treatment for
prostate cancer, cryosurgery is not as effective as surgery or radiation. However, cryosurgery is potentially better than radical
prostatectomy for recurrent cancer following radiation therapy.
Hormonal therapy uses medications or surgery to
block prostate cancer cells from getting dihydrotestosterone (DHT), a
hormone produced in the prostate and required for the growth and spread of
most prostate cancer cells. Blocking DHT often causes prostate cancer to
stop growing and even shrink. However, hormonal therapy rarely cures
prostate cancer because cancers which initially respond to hormonal
therapy typically become resistant after one to two years. Hormonal
therapy is therefore usually used when cancer has spread from the
prostate. It may also be given to certain men undergoing radiation therapy
or surgery to help prevent return of their cancer.
Hormonal therapy in prostate cancer.
Diagram shows the different organs (purple text), hormones (black text and
arrows), and treatments (red text and arrows) important in hormonal therapy.
Hormonal therapy for prostate cancer targets the
pathways the body uses to produce DHT. A feedback loop involving the
testicles, the hypothalamus, and the pituitary, adrenal, and prostate
glands controls the blood levels of DHT. First, low blood levels of DHT
stimulate the hypothalamus to produce gonadotropin releasing hormone (GnRH).
GnRH then stimulates the pituitary gland to produce luteinizing hormone (LH),
and LH stimulates the testicles to produce testosterone. Finally,
testosterone from the testicles and dehydroepiandrosterone from the
adrenal glands stimulate the prostate to produce more DHT. Hormonal
therapy can decrease levels of DHT by interrupting this pathway at any
There are several forms of hormonal therapy:
|| Orchiectomy is surgery to remove the testicles.
Because the testicles make most of the body's testosterone, after
orchiectomy testosterone levels drop. Now the prostate not only lacks the
testosterone stimulus to produce DHT, but also it does not have enough
testosterone to transform into DHT.
|| Antiandrogens are medications such as flutamide,
bicalutamide, nilutamide, and cyproterone acetate which directly block the
actions of testosterone and DHT within prostate cancer cells.
|| Medications which block the production of adrenal
androgens such as DHEA include ketoconazole and aminoglutethimide. Because
the adrenal glands only make about 5% of the body's androgens, these
medications are generally used only in combination with other methods that
can block the 95% of androgens made by the testicles. These combined
methods are called total androgen blockade (TAB). TAB can also be achieved
|| GnRH action can be interrupted in one of two
ways. GnRH antagonists suppress the production of GnRH directly, while
GnRH agonists suppress GnRH through the process of downregulation after an
initial stimulation effect. Abarelix is an example of a GnRH antagonist,
while the GnRH agonists include leuprolide, goserelin, triptorelin, and
buserelin. Initially, these medications increase the production of LH.
However, because the constant supply of the medication does not match the
body's natural production rhythm, production of both LH and GnRH decreases
after a few weeks.
As of 2006 the most successful hormonal treatments
are orchiectomy and GnRH agonists. Despite their higher cost, GnRH
agonists are often chosen over orchiectomy for cosmetic and emotional
reasons. Eventually, total androgen blockade may prove to be better than
orchiectomy or GnRH agonists used alone.
Each treatment has disadvantages which limit its
use in certain circumstances. Although orchiectomy is a low-risk surgery,
the psychological impact of removing the testicles can be significant. The
loss of testosterone also causes hot flashes, weight gain, loss of libido,
enlargement of the breasts (gynecomastia), impotence and osteoporosis.
GnRH agonists eventually cause the same side effects as orchiectomy but
may cause worse symptoms at the beginning of treatment. When GnRH agonists
are first used, testosterone surges can lead to increased bone pain from
metastatic cancer, so antiandrogens or abarelix are often added to blunt
these side effects. Estrogens are not commonly used because they increase
the risk for cardiovascular disease and blood clots. The antiandrogens do
not generally cause impotence and usually cause less loss of bone and
muscle mass. Ketoconazole can cause liver damage with prolonged use, and
aminoglutethimide can cause skin rashes.
Palliative care for advanced stage prostate cancer
focuses on extending life and relieving the symptoms of metastatic
disease. Chemotherapy may be offered to slow disease progression and
postpone symptoms. The most commonly used regimen combines the
chemotherapeutic drug docetaxel with a corticosteroid such as prednisone.
Bisphosphonates such as zoledronic acid have been shown to delay skeletal
complications such as fractures or the need for radiation therapy in
patients with hormone-refractory metastatic prostate cancer.
Bone pain due to metastatic disease is treated with
opioid pain relievers such as morphine and oxycodone. External beam
radiation therapy directed at bone metastases may provide pain relief.
Injections of certain radioisotopes, such as strontium-89, phosphorus-32,
or samarium-153, also target bone metastases and may help relieve pain.
Prostate cancer rates are higher and prognosis
poorer in Western societies than the rest of the world. Many of the risk
factors for prostate cancer are more prevalent in the Western world,
including longer life expectancy and diets high in animal fats. Also,
where there is more access to screening programs, there is a higher
detection rate. Prostate cancer is the ninth most common cancer in the
world, but is the number one non-skin cancer in United States men.
Prostate cancer affected eighteen percent of American men and caused death
in three percent in 2005. In Japan, death from prostate cancer was
one-fifth to one-half the rates in the United States and Europe in the
1990s. In India in the 1990s, half of the people with prostate cancer
confined to the prostate died within ten years. African-American men
have 50-60 times more prostate cancer and prostate cancer deaths than men
in Shanghai, China. In Nigeria, two percent of men develop prostate cancer
and 64% of them are dead after two years.
In patients who undergo treatment, the most
important clinical prognostic indicators of disease outcome are stage,
pre-therapy PSA level and Gleason score. In general, the higher the grade
and the stage, the poorer the prognosis. Nomograms can be used to
calculate the estimated risk of the individual patient. The predictions
are based on the experience of large groups of patients suffering from
cancers at various stages.
Although the prostate was first described by
Venetian anatomist Niccolò Massa in 1536, and illustrated by Flemish
anatomist Andreas Vesalius in 1538, prostate cancer was not identified
until 1853. Prostate cancer was initially considered a rare disease,
probably because of shorter life expectancies and poorer detection methods
in the 19th century. The first treatments of prostate cancer were
surgeries to relieve urinary obstruction. Removal of the entire gland
(radical perineal prostatectomy) was first performed in 1904 by Hugh Young
at Johns Hopkins Hospital. Surgical removal of the testes (orchiectomy)
to treat prostate cancer was first performed in the 1890s, but with
limited success. Transurethral resection of the prostate (TURP) replaced
radical prostatectomy for symptomatic relief of obstruction in the middle
of the 20th century because it could better preserve penile erectile
function. Radical retropubic prostatectomy was developed in 1983 by
Patrick Walsh. This surgical approach allowed for removal of the
prostate and lymph nodes with maintenance of penile function.
In 1941 Charles B. Huggins published studies in
which he used estrogen to oppose testosterone production in men with
metastatic prostate cancer. This discovery of "chemical
castration" won Huggins the 1966 Nobel Prize in Physiology or
Medicine. The role of the hormone GnRH in reproduction was determined by
Andrzej W. Schally and Roger Guillemin, who both won the 1977 Nobel Prize
in Physiology or Medicine for this work. Receptor agonists, such as
leuprolide and goserelin, were subsequently developed and used to treat
Radiation therapy for prostate cancer was first
developed in the early 20th century and initially consisted of
intraprostatic radium implants. External beam radiation became more
popular as stronger radiation sources became available in the middle of
the 20th century. Brachytherapy with implanted seeds was first described
Systemic chemotherapy for prostate cancer was first
studied in the 1970s. The initial regimen of cyclophosphamide and
5-fluorouracil was quickly joined by multiple regimens using a host of
other systemic chemotherapy drugs.
Diabetes is a set of
diseases in which the body cannot regulate the amount of glucose, or
sugar, in the blood. Glucose in the blood gives your body energy. The
pancreas is an organ that creates a hormone called insulin. Insulin
allows glucose to move from the blood into liver, muscle, and fat cells,
where it is used for fuel. When a person has diabetes, their body either
doesn't make enough insulin or can't use its own insulin as well as it
should. This causes sugar to build up in your blood.
Approximately, there are
20 million people in the United States, or 7% of the population, who
have diabetes. While an estimated 14.6 million have been diagnosed with
diabetes, 6.2 million people, or nearly one-third, are unaware that they
have the disease.
Type 1 diabetes is an
autoimmune disease in which the immune system attacks the beta cells in
the pancreas that make insulin. This makes the pancreas make less amount
of make insulin, a hormone which helps turn blood sugar into energy. The
cells become starved of energy and there is an excess of glucose in the
blood. People with Type 1 diabetes must have daily injections of insulin
to live. Proper diet, exercise and home blood sugar monitoring is
essential to manage the disease. If your blood sugar level becomes very
high, a life-threatening chemical imbalance called diabetic ketoacidosis
Type 1 diabetes can
develop at any age. However, it usually develops in children and young
adults, which is why it used to be called juvenile diabetes. About 5-10%
of people with diabetes have type 1.
Treatment for type 1
diabetes focuses on keeping blood sugar levels within a target range.
Usual treatments are:
sugar levels at home.
People with type 1
diabetes can live long, healthy lives if they keep their blood sugar
levels as close to normal as possible.
Type 2 diabetes is a
lifelong disease that develops when the pancreas cannot produce enough
insulin or when the body's tissues become resistant to insulin. Insulin
helps sugar glucose enter cells, where it is used for energy. It also
helps the body store extra sugar in muscle, fat, and liver cells.
When insulin is not
available or is not used properly, blood sugar rises above a safe level.
If blood sugar remains high for years, blood vessels and nerves
throughout the body may be damaged. This puts you at increased risk for
eye, heart, blood vessel, nerve, and kidney disease. Type 2 diabetes can
develop at any age, although it usually develops in adults. Between
90-95% of people with diabetes have type 2.
Type 2 diabetes is
caused by insulin resistance, which occurs when the body's cells and
tissues do not respond properly to insulin. An individual’s weight,
level of physical activity, and family history affect how your body
responds to insulin. People who are overweight, get little or no
exercise, or have diabetes in their family have an increased risk of
developing type 2 diabetes.
Risk factors for type 2
diabetes include older age, obesity, family history, physical
inactivity, and race/ethnicity. African Americans, Hispanic/Latino
Americans, American Indians, and some Pacific Islanders are at
particularly high risk for type 2 diabetes.
What other complications
can diabetes lead to?
disease and stroke: Heart
disease and stroke account for about 65% of deaths in people with
blood pressure: About
73% of adults with diabetes have high blood pressure.
Diabetes is the leading cause
of new cases of blindness among adults aged 20–74years.
is the leading cause of kidney failure, accounting for 40% of new
system disease: About
60-70% of people with diabetes have mild to severe forms of nervous
More than 60% of non-traumatic
leg amputations occur in people with diabetes.
30% of people with diabetes have severe gum disease.
Cholesterol is a
white-colored waxy substance found in cell membranes and is required for the
body to help produce other cell membranes and a variety of hormones. The
majority of cholesterol is produced by the liver, and the cholesterol levels
found in our blood are affected by the types of foods we eat. Excessive amounts
of cholesterol can build up in the arterial walls over time, thus causing
hardening and narrowing of the blood vessels. When this occurs it increases the
risk of heart disease by reducing the flow of blood.
Causes of high cholesterol
too high in saturated fats
trait of high cholesterol
Certain foods contain high
amounts of cholesterol, and people who are concerned about reducing their
cholesterol intake should avoid the following foods:
butter, cheese, ice cream, milk
fats, shortening and some margarines
salami and other similar meats
Others can be
beneficial in striving to reduce cholesterol levels. These foods include the
grain bread, cereals, brown rice and whole grain pasta
skin items, i.e.: potatoes (with skin on)
grain rolled oats, oat bran
meats , skinned poultry and fish
Most people can reduce
cholesterol by 10 to 20% by watching their diet. In many cases this is not
enough and therefore other remedies are necessary. Medication may be required
and research has shown that new drugs can be very effective in reducing
Kidney stones, also known as nephrolithiasis,
urolithiasis or renal calculi, are solid concretions (crystal
aggregations) of dissolved minerals in urine found inside the kidneys or
ureters. They vary in size from as small as a grain of sand to as large as
a grapefruit. Kidney stones typically leave the body in the urine stream;
if they grow relatively large before passing (on the order of at least 2-3
millimeters), obstruction of a ureter and distention with urine can cause
severe pain most commonly felt in the flank, lower abdomen and groin. Such
pain, called renal colic, often comes in waves and can be particularly
severe. Nausea is associated with this particular pain primarily due to
the embyrological association of the kidneys and the intestinal tract.
Recurrence rates are estimated at about 10% per year. Kidney stones are
totally unrelated to gallstones.
An 8-mm kidney
Conventional wisdom and common sense has long held
that consumption of too much calcium can aggravate the development of
kidney stones, since the most common type of stone is calcium oxalate.
However, strong evidence has accumulated demonstrating that low-calcium
diets are associated with higher overall stone risk for the typical stone
former. This is thought to be due to the binding of ingested intestinal
oxalate with calcium in the gastrointestinal tract. Such oxalate binding
would prevent oxalate absorption resulting in lower urinary oxalate
levels. In the urine, oxalate is a very strong promotor of crystal and
stone formation, about 15 times stronger than calcium.
Other examples of kidney stones include struvite
(magnesium, ammonium and phosphate), uric acid, calcium phosphate, or
cystine (found only in people suffering from cystinuria). The formation of
struvite stones is associated with the presence of urea-splitting
bacteria, most commonly Proteus mirabilis (also Klebsiella, Serratia,
Providencia species) which can split urea into ammonia, resulting in
favorable conditions for the formation of struvite. Calcium phosphate is
associated with metabolic disorders like hyperparathyroidism and renal
tubular acidosis while uric acid stones are most common in patients with
gout or other disorders of acid/base metabolism.
Renal calculi can occur due to other underlying
conditions, such as renal tubular acidosis, Dent's disease and medullary
sponge kidney, which are screened for in some centers in those with
recurrent urinary calculi formation.
Kidney stones are usually asymptomatic until they
obstruct the flow of urine. Symptoms can include acute flank pain (renal
colic), nausea and vomiting, restlessness, dull pain, hematuria, and
possibly fever if an infection is present. Acute renal colic is described
as one of the worst types of pain that a patient can suffer. Note that the
pain is generally due to the stone's presence in the ureter, and not—as
is commonly believed—the urethra and lower genitals.
Some patients show no symptoms until their urine
turns bloody—this may be the first symptom of a kidney stone. The amount
of blood may not be sufficient to be seen, and thus the first warning can
be microscopic hematuria, when red blood cells are found in the
microscopic study of a urine sample, during a routine medical test.
However, not every kidney stone patient demonstrates blood in urine, even
microscopically. About 15% of proven kidney stone patients may not show
even microscopic hematuria so this is not considered a definitive
Diagnosis & Investigation
Diagnosis is usually made on the basis of the
location and severity of the pain, which is typically colic in nature
(comes and goes in spasmodic waves). Radiological imaging is used to
confirm the diagnosis and a number of other tests can be undertaken to
help establish both the possible cause and consequences of the stone.
Ultrasound imaging is also useful as it will give details about the
presence of hydronephrosis (swelling of the kidney - suggesting the stone
is blocking the outflow of urine). It can also be used to show the kidneys
during pregnancy when standard x-rays are discouraged. About 10% of stones
do not have enough calcium to be seen on standard x-rays (radiolucent
stones) and may show up on ultrasound although they typically are seen on
The relatively dense calcium renders these stones
radio-opaque and they can be detected by a traditional X-ray of the
abdomen that includes Kidneys, Ureters and Bladder—KUB. This may be
followed by an IVP (Intravenous Pyelogram; IntraVenous Urogram (IVU) is
the same test by another name) which requires about 50ml of a special dye
to be injected into the bloodstream that is excreted by the kidneys and by
its density helps outline any stone on a repeated X-ray. These can also be
detected by a Retrograde pyelogram where similar "dye" is
injected directly into the ureteral opening in the bladder by a surgeon,
usually a urologist. Computed tomography (CT or CAT scan), a specialized
X-ray, is considered the gold-standard diagnostic test for the detection
of kidney stones, and in this setting does not require the use of
intravenous contrast, which carries some risk in certain people (eg,
allergy, kidney damage). All stones are detectable by CT except very rare
stones composed of certain drug residues in urine. The non-contrast
"renal colic study" CT scan has become the standard test for the
immediate diagnosis of flank pain typical of a kidney stone. If positive
for stones, a single standard x-ray of the abdomen (KUB) is recommended.
This additional x-ray provides the physicians with a clearer idea of the
exact size and shape of the stone as well as its surgical orientation.
Further, it makes it simple to follow the progress of the stone without
the need for the much more expensive CT scan just by doing another single
x-ray at some point in the future.
Investigations typically carried out include:
|| Microscopic study of urine, which may show
proteins, red blood cells, pus cells, cellular casts and crystals.
|| Culture of a urine sample to exclude urine
infection (either as a differential cause of the patient's pain, or
secondary to the presence of a stone)
|| Blood tests: Full blood count for the presence of
a raised white cell count (Neutrophilia) suggestive of infection, a check
of renal function and if raised blood calcium blood levels (hypercalcaemia).
|| 24 hour urine collection to measure total daily
urinary volume, magnesium, sodium, uric acid, calcium, citrate, oxalate
90% of stones 4 mm or less in size usually will
pass spontaneously, however the majority of stones greater than 6 mm will
require some form of intervention. In most cases, a smaller stone that is
not symptomatic is often given up to 30 days to move or pass before
consideration is given to any surgical intervention as it's been found
that waiting longer tends to lead to additional complications. Immediate
surgery may be required in certain situations such as in people with only
one working kidney, intractable pain or in the presence of an infected
kidney blocked by a stone which can rapidly cause severe sepsis and toxic
Management of pain from kidney stones varies from
country to country and even from physician to physician, but may require
intravenous medication (eg, narcotic or nonsteroidal anti-inflammatories)
in acute situations. Similar classes of drugs may be effectve orally in an
outpatient setting for less severe discomfort. Intravenous ketorolac (Toradol)
has been found to be quite effective in many cases of acute renal colic to
control the pain without the need for narcotic medications. Ketorolac is a
non-steroidal anti-inflammatory that is related to aspirin and ibuprofen.
Most acute kidney stone pain will last less than 24 hours and not require
hospitalization. Patients are encouraged to strain their urine so they can
collect the stone when it eventually passes and send it for chemical
In many cases non-invasive Extracorporeal Shock
Wave Lithotripsy or (ESWL) may be used. Otherwise some form of invasive
procedure is required; with approaches including ureteroscopic
fragmentation (or simple basket extraction if feasible) using laser,
ultrasonic or mechanical (pneumatic, shock-wave) forms of energy to
fragment the stones. Percutaneous nephrolithotomy or open surgery may
ultimately be necessary for large or complicated stones or stones which
fail other less invasive attempts at treatment.
A single retrospective study in the USA, at the
Mayo Clinic, has suggested that lithotripsy may increase subsequent
incidence of diabetes and hypertension, but it has not been felt
warranted to change clinical practice at the clinic. The study reflects
early experience with the original lithotripsy machine which had a very
large blast path, much larger than what is used on modern machines.
Further study is believed necessary to determine how much risk this
treatment actually has using modern machines and treatment regimens.
Preventive strategies include dietary modifications
and sometimes also taking drugs with the goal of reducing excretory load
on the kidneys:
|| Drinking enough water to make 2 to 2.5 litres of
urine per day.
|| A diet low in protein, nitrogen and sodium
|| Restriction of oxalate-rich foods and maintaining
an adequate intake of dietary calcium is recommended. There is equivocal
evidence that calcium supplements increase the risk of stone formation,
though calcium citrate appears to carry the lowest, if any, risk.
|| Taking drugs such as thiazides, potassium
citrate, magnesium citrate and allopurinol depending on the cause of stone
|| Depending on the stone formation disease, vitamin
B-6 and orthophosphate supplements may be helpful, although these
treatments are generally reserved for those with Hyperoxaluria. Cellulose
supplements have also shown potential for reducing kidney stones caused by
hypercalciuria (excessive urinary calcium) although today other means are
generally used as cellulose therapy is associated with significant side
Certain foods may increase the risk of stones:
spinach, rhubarb, chocolate, peanuts, cocoa, tomato juice, grapefruit
juice, apple juice, soda (acidic and contains phosphorus), and berries
(high levels of oxalate). In the United States, the South has the highest
incidence of kidney stones, a region where sweet tea consumption is very
common. Other drinks are associated with decreased risk of stones,
including wine, lemonade and orange juice, the latter two of which are
rich in citrate, a stone inhibitor.
Although it has been claimed that the diuretic
effects of alcohol can result in dehydration, which is important for
kidney stones sufferers to avoid, there are no conclusive data
demonstrating any cause and effect regarding kidney stones. However, some
have theorized that frequent and binge drinkers create situations that set
up dehydration, (alcohol consumption, hangovers, and poor sleep and stress
habits). In this view, it is not the alcohol that creates a kidney stone
but it is the alcohol drinker's associated behavior that sets it up.
One of the recognized medical therapies for
prevention of stones is thiazides, a class of drugs usually thought of as
diuretic. These drugs prevent stones through an effect independent of
their diuretic properties: they reduce urinary calcium excretion.
Nonetheless, their diuretic property does not preclude their efficacy as
stone preventive. Sodium restiction is necessary for clinical effect of
thiazides, as sodium excess promotes calcium excretion. Though some have
said that the effect probably fades after two years or so of therapy (tachyphylaxis),
in fact it is only randomized controlled trials lasting 2 years or more
that show the effect; there is really no good evidence from studies of
calcium metabolism that the thiazide effect does not last indefinitely.
Thiazides are the medical therapy of choice for most cases of
hypercalciuria (excessive urinary calcium) but may not be suitable for all
calcium stone formers; just those with high urinary calcium levels.
Allopurinol (Zyloprim) is another drug with proven
benefits in some calcium kidney stone formers. Allopurinol interferes with
the liver's production of uric acid. Hyperuricosuria, too much uric acid
in the urine, is a risk factor for calcium stones. Allopurinol reduces
calcium stone formation in such patients. The drug is also used in
patients with gout or hyperuricemia, but hyperuricosuria is not the
critical feature of uric acid stones. Uric acid stones are more often
caused by low urine pH. Even relatively high uric acid excretion will not
be associated with uric acid stone formation if the urine pH is alkaline.
Therefore prevention of uric acid stones relies on alkalinization of the
urine with citrate. Allopurinol is reserved for patients in whom
alkalinization is difficult. For patients with increased uric acid levels
and calcium stones, alloprinol is one of the few treatments that has been
shown in double-blinded placebo controlled studies to actually reduce
kidney stone recurrences. Dosage is adjusted to maintain
a reduced urinary excretion of uric acid. Serum uric acid level at or
below 6 mg/dL is often the goal of the drug's use in patients with gout or
Potassium citrate is also used in kidney stone
prevention. This is available as both a tablet and liquid preparation. The
medication will increase the urinary pH making it more alkaline as well as
increasing the urinary citrate level which helps reduce calcium oxalate
crystal aggregation. Optimal 24 hour urine levels of citrate are thought
to be over 320 mg/liter of urine or over 600 mg per day. There are urinary
dipsticks available that allow patients to monitor and measure urinary pH
so patients can optimize their urinary citrate level.
Though caffeine does acutely increase urinary
calcium excretion, several independent epidemiologic studies have shown
that coffee intake overall is protective for stones.
Measurements of food oxalate content have been
difficult and issues remain about the proportion of oxalate that is
bio-available, versus a proportion that is not absorbed by the intestine.
Oxalate-rich foods are usually restricted to some degree, particularly in
patients with high urinary oxalate levels, but no randomized controlled
trial of oxalate restriction has been performed to test that hypothesis.
A high protein diet might be partially to blame.
Protein from meat and other animal products is broken down into acids,
including uric acid. The most available alkaline base to balance the acid
from protein is calcium phosphate (hydroxyapatite) from the bones
(buffering). The kidney filters the liberated calcium which may then form
insoluble crystals (ie, stones) in urine with available oxalate (partly
from metabolic processes, partly from diet) or phosphate ions depending on
conditions. High protein intake is therefore associated with decreased
bone density as well as stones. The acid load is associated with decreased
urinary citrate excretion; citrate competes with oxalate for calcium and
can thereby prevent stones. One of the simplest fixes in addition to
increased fluid intake is to moderate animal protein consumption. However,
despite epidemiologic data showing that more protein intake is associated
with more stones, randomized controlled trials of protein restriction have
not shown reduced stone prevalence. In this regard, it is not just dietary
calcium per se that may cause stone formation, but rather the leaching of
bone calcium. Some diseases (eg, distal renal tubular acidosis) which
cause a chronically acidic state also decrease urinary citrate levels;
since citrates are normally present as potent inhibitors of stone
formation, these patients are prone to frequent stone formation.
For those patients interested in optimizing their
kidney stone prevention options, it's essential to have a 24 hour urine
test performed. This should be done with the patient on his or her regular
diet and activities. The results can then be analyzed for abnormalities
and appropriate treatment given.
Famous Kidney Stone
| In 271 or 270 BC, the Greek Philosopher
died from a kidney stone blockage lasting a fortnight according to his
successor Hermarchus and reported by his biographer Diogenes Laertius.
| French Renaissance essayist Montaigne suffered
from kidney stones. British statesman Samuel Pepys also suffered from
kidney stones and was operated on, pre-anesthesia, to remove a large stone
which he carried with him and used to try to persuade fellow sufferers to
endure the painful surgery. His contemporary, John Wilkins, Bishop of
Chester, could not face the prospect and died as a result.
| Dutch blacksmith Jan de Doot is remembered for
having his portrait painted with the large stone that he removed from
himself in 1651.
| Author Chuck Palahniuk wrote about his experience
with a kidney stone in his nonfiction book Stranger Than Fiction: True
| Author Isaac Asimov suffered from kidney stones,
and wrote about how his pain was treated with morphine, saying that he
feared becoming addicted to morphine if he ever needed it again.
| Astronauts often get kidney stones because of an
increase in the amount of calcium in their blood due to a loss of bone
density in zero gravity.
| In his book, "A Year At the
Movies", Mystery Science
Theatre 3000 writer/performer Kevin Murphy describes his ordeal with a
kidney stone: "Being gut-stabbed with a dirty spoon in a prison
cafeteria is less painful."
| Former Speaker of the House of Representatives,
Dennis Hastert, has had a number of kidney stones. Hastert had to have
kidney stone removal surgery.
| Lyndon B. Johnson suffered from kidney stones at
various times in his life. See Woods, "LBJ: Architect of American
| While DJ'ing at a student event, British DJ
Peel passed a kidney stone, and then proceeded to auction it off for
charity at the same event.
| On October 19, 2005, while working on the set of
Boston Legal, actor William Shatner was taken to the emergency room for
lower back pain. He eventually passed a kidney stone, but recovered and
soon returned to work. Shatner sold his kidney stone in 2006 for $75,000
to GoldenPalace.com. The money will go to a housing charity.
| Minnesota Twins catcher Joe Mauer has also
suffered from kidney stones, when asked about it he stated, "I don't
wish that on anyone."
| Reggaeton artist Tito El Bambino briefly suffered
from kidney stones.
| Karl Pilkington was diagnosed with kidney stones
in late August 2006
| John Hart, signer of the Declaration of
Independence, died of kidney stones.
| Tycho Brahe, astronomer.
| Peter Baulman (Australia) had a kidney stone
removed from his right kidney in December 2003 at The Gold Coast Hospital,
Southport, Queensland, Australia, weighing 356 g (12.5 oz) and measuring
at its widest point, 11.86 cm (4.66 in). It holds the Guinness world
record for largest and heaviest kidney stone removed from a human being.
Bladder cancer refers to any of several types of
malignant growths of the urinary bladder. It is a disease in which
abnormal cells multiply without control in the bladder. The bladder is a
hollow, muscular organ that stores urine; it is located in the pelvis. The
most common type of bladder cancer begins in cells lining the inside of
the bladder and is called urothelial cell or transitional cell carcinoma (UCC
Exposure to environmental carcinogens of various
types is responsible for the development of most bladder cancers. Tobacco
abuse (specifically cigarette smoking) is thought to cause 50% of bladder
cancers discovered in male patients and 30% of those found in female
patients. Thirty percent of bladder tumors probably result from
occupational exposure in the workplace to carcinogens such as benzidine.
Approximately 20% of bladder cancers occur in patients without
predisposing risk factors. Bladder cancer is not currently believed to be
heritable (i.e., does not "run in families" as a consequence of
a specific genetic abnormality).
Signs and symptoms
Bladder cancer may cause blood in the urine, pain
during urination, frequent urination, or feeling the need to urinate
without results. These signs and symptoms are not specific to bladder
cancer, and are also caused by noncancerous conditions, including prostate
infections and cystitis.
The treatment of bladder cancer depends on how deep
the tumor invades into the bladder wall. Superficial tumors (those not
entering the muscle layer) can be "shaved off" using an
electrocautery device attached to a cystoscope. Immunotherapy in the form
of BCG instillation is also used to treat and prevent the recurrence of
superficial tumors. BCG immunotherapy is effective in up to 2/3 of the
cases at this stage. Instillations of chemotherapy into the bladder can
also be used to treat superficial disease.
Untreated, superficial tumors may gradually begin
to infiltrate the muscular wall of the bladder. Tumors that infiltrate the
bladder require more radical surgery where part or all of the bladder is
removed (a cystectomy) and the urinary stream is diverted. In some cases,
skilled surgeons can create a substitute bladder (a neobladder) from a
segment of intestinal tissue, but this largely depends upon patient
preference, age of patient, renal function, and the site of the disease.
A combination of radiation and chemotherapy can
also be used to treat invasive disease, and, in many cases, it is not yet
known which is the better treatment - radiotherapy or radical ablative
There is weak observational evidence from one very
small study (84) to suggest that the concurrent use of statins is
associated with a worse outcome.
In the United States, bladder cancer is the fourth
most common type of cancer in men and the ninth most common cancer in
women. More than 47,000 men and 16,000 women are diagnosed with bladder
cancer each year.
Bladder cancer is not linked to specific genes;
however some which are more prominently studied include the FGFR3, HRAS,
RB1 and TP53 genes. As with most cancers, the exact causes of bladder
cancer are not known; however, many risk factors are associated with this
disease. Chief among them are smoking, followed by exposure to certain
chemicals. Mutations in the gene that arise in the bladder are another
important risk factor for developing bladder cancer. Several genes have
been identified which play a role in regulating the cycle of cell
division, preventing cells from dividing too rapidly or in an uncontrolled
way. Alterations in these genes may help explain why some bladder cancers
grow and spread more rapidly than others.
Bladder cancer is generally not inherited; tumors
usually result from genetic mutations that occur in certain bladder cells
during a person's lifetime. These noninherited genetic changes are called
somatic mutations. A family history of bladder cancer is, however, a risk
factor for the disease. Along these lines, some people appear to inherit a
reduced ability to break down certain chemicals, which makes them more
sensitive to the cancer-causing effects of tobacco smoke and certain
Development of the Urinary and
Note: this article is taken from the public domain
1918 Gray's Anatomy. As such, it may be in need of updating to reflect
modern medical knowledge and modern writing style.
In human fetal development, the urinary and
reproductive organs are developed from the intermediate cell-mass which is
situated between the primitive segments and the lateral plates of
mesoderm. The permanent organs of the adult are preceded by a set of
structures which are purely embryonic, and which with the exception of the
ducts disappear almost entirely before the end of fetal life. These
embryonic structures are on either side; the pronephros, the mesonephros,
the metanephros, and the Wolffian and Müllerian ducts. The pronephros
disappears very early; the structural elements of the mesonephros mostly
degenerate, but in their place is developed the genital gland in
association with which the Wolffian duct remains as the duct of the male
genital gland, the Müllerian as that of the female; some of the tubules
of the metanephros form part of the permanent kidney.
The Pronephros and Wolffian Duct
In the outer part of the intermediate cell-mass,
immediately under the ectoderm, in the region from the fifth cervical to
the third thoracic segments, a series of short evaginations from each
segment grows dorsalward and extends caudalward, fusing successively from
before backward to form the pronephric duct. This continues to grow
caudalward until it opens into the ventral part of the cloaca; beyond the
pronephros it is termed the Wolffian duct.
The original evaginations form a series of
transverse tubules each of which communicates by means of a funnel-shaped
ciliated opening with the celomic cavity, and in the course of each duct a
glomerulus also is developed. A secondary glomerulus is formed ventral to
each of these, and the complete group constitutes the pronephros. The
pronephros undergoes rapid atrophy and disappears.
The Mesonephros, Müllerian Duct, and Genital Gland
On the medial side of the Wolffian duct, from the
sixth cervical to the third lumbar segments, a series of tubules, the
Wolffian tubules, is developed; at a later stage in development they
increase in number by outgrowths from the original tubules. These tubules
first appear as solid masses of cells, which later become hollowed in the
center; one end grows toward and finally opens into the Wolffian duct, the
other dilates and is invaginated by a tuft of capillary bloodvessels to
form a glomerulus. The tubules collectively constitute the mesonephros or
By the fifth or sixth week this body forms an
elongated spindle-shaped structure, termed the urogenital fold (Fig.
1106), which projects into the celomic cavity at the side of the dorsal
mesentery, reaching from the septum transversum in front to the fifth
lumbar segment behind; in this fold the reproductive glands are developed.
The Wolffian bodies persist and form the permanent kidneys in fishes and
amphibians, but in reptiles, birds, and mammals, they atrophy and for the
most part disappear coincidently with the development of the permanent
kidneys. The atrophy begins during the sixth or seventh week and rapidly
proceeds, so that by the beginning of the fifth month only the ducts and a
few of the tubules remain.
In the male the Wolffian duct persists, and forms
the tube of the epididymis, the ductus deferens and the ejaculatory duct,
while the seminal vesicle arises during the third month as a lateral
diverticulum from its hinder end. A large part of the head end of the
mesonephros atrophies and disappears; of the remainder the anterior
tubules form the efferent ducts of the testis; while the posterior tubules
are represented by the ductuli aberrantes, and by the paradidymis, which
is sometimes found in front of the spermatic cord above the head of the
In the female the Wolffian bodies and ducts
atrophy. The remains of the Wolffian tubules are represented by the
epoöphoron or organ of Rosenmüller, and the paroöphoron, two small
collections of rudimentary blind tubules which are situated in the
mesosalpinx. The lower part of the Wolffian duct disappears, while the
upper part persists as the longitudinal duct of the epoöphoron or duct of
The Müllerian Ducts
Shortly after the formation of the Wolffian ducts a
second pair of ducts is developed; these are named the Müllerian ducts.
Each arises on the lateral aspect of the corresponding Wolffian duct as a
tubular invagination of the cells lining the celom. The orifice of the
invagination remains patent, and undergoes enlargement and modification to
form the abdominal ostium of the uterine tube. The ducts pass backward
lateral to the Wolffian ducts, but toward the posterior end of the embryo
they cross to the medial side of these ducts, and thus come to lie side by
side between and behind the latter—the four ducts forming what is termed
the genital cord. The Müllerian ducts end in an epithelial elevation, the
Müllerian eminence, on the ventral part of the cloaca between the
orifices of the Wolffian ducts; at a later date they open into the cloaca
in this situation.
In the male the Müllerian ducts atrophy, but
traces of their anterior ends are represented by the appendices testis (hydatids
of Morgagni), while their terminal fused portions form the utriculus in
the floor of the prostatic portion of the urethra.
In the female the Müllerian ducts persist and
undergo further development. The portions which lie in the genital core
fuse to form the uterus and vagina; the parts in front of this cord remain
separate, and each forms the corresponding uterine tube—the abdominal
ostium of which is developed from the anterior extremity of the original
tubular invagination from the coelom. The fusion of the Müllerian ducts
begins in the third month, and the septum formed by their fused medial
walls disappears from below upward, and thus the cavities of the vagina
and uterus are produced. About the fifth month an annular constriction
marks the position of the neck of the uterus, and after the sixth month
the walls of the uterus begin to thicken. For a time the vagina is
represented by a solid rod of epithelial cells. A ring-like outgrowth of
this epithelium occurs at the lower end of the uterus and marks the future
vaginal fornices; about the fifth or sixth month the lumen of the vagina
is produced by the breaking down of the central cells of the epithelium.
The hymen represents the remains of the Müllerian eminence.
The first appearance of the genital gland is
essentially the same in the two sexes, and consists in a thickening of the
epithelial layer which lines the peritoneal cavity on the medial side of
the urogenital fold. The thick plate of epithelium extends deeply, pushing
before it the mesoderm and forming a distinct projection. This is termed
the genital ridge, and from it the testis in the male and the ovary in the
female are developed. At first the mesonephros and genital ridge are
suspended by a common mesentery, but as the embryo grows the genital ridge
gradually becomes pinched off from the mesonephros, with which it is at
first continuous, though it still remains connected to the remnant of this
body by a fold of peritoneum, the mesorchium or mesovarium. About the
seventh week the distinction of sex in the genital ridge begins to be
The ovary, thus formed from the genital ridge, is
at first a mass of cells derived from the celomic epithelium; later the
mass is differentiated into a central part or medulla covered by a surface
layer, the germinal epithelium. Between the cells of the germinal
epithelium a number of larger cells, the primitive ova, are found, and
these are carried into the subjacent stroma by bud-like ingrowths (genital
cords) of the germinal epithelium. The surface epithelium ultimately forms
the permanent epithelial covering of this organ; it soon loses its
connection with the central mass, and a tunica albuginea develops between
them. The ova are chiefly derived from the cells of the central mass;
these are separated from one another by the growth of connective tissue in
an irregular manner; each ovum assumes a covering of connective tissue
(follicle) cells, and in this way the rudiments of the ovarian follicles
are formed. According to Beard the primitive ova are early set apart
during the segmentation of the ovum and migrate into the germinal ridge.
The testis is developed in much the same way as the
ovary. Like the ovary, in its earliest stages it consists of a central
mass of epithelium covered by a surface epithelium. In the central mass a
series of cords appear, and the periphery of the mass is converted into
the tunica albuginea, thus excluding the surface epithelium from any part
in the formation of the tissue of the testis. The cords of the central
mass run together toward the future hilus and form a network which
ultimately becomes the rete testis. From the cords the seminiferous
tubules are developed, and between them connective-tissue septa extend.
The seminiferous tubules become connected with outgrowths from the
Wolffian body, which, as before mentioned, form the efferent ducts of the
Descent of the Testes
The testes, at an early period of fetal life, are
placed at the back part of the abdominal cavity, behind the peritoneum,
and each is attached by a peritoneal fold, the mesorchium, to the
mesonephros. From the front of the mesonephros a fold of peritoneum termed
the inguinal fold grows forward to meet and fuse with a peritoneal fold,
the inguinal crest, which grows backward from the antero-lateral abdominal
wall. The testis thus acquires an indirect connection with the anterior
abdominal wall; and at the same time a portion of the peritoneal cavity
lateral to these fused folds is marked off as the future saccus vaginalis.
In the inguinal crest a peculiar structure, the gubernaculum testis, makes
its appearance. This is at first a slender band, extending from that part
of the skin of the groin which afterward forms the scrotum through the
inguinal canal to the body and epididymis of the testis. As development
advances, the peritoneum enclosing the gubernaculum forms two folds, one
above the testis and the other below it. The one above the testis is the
plica vascularis, and contains ultimately the internal spermatic vessels;
the one below, the plica gubernatrix, contains the lower part of the
gubernaculum, which has now grown into a thick cord; it ends below at the
abdominal inguinal ring in a tube of peritoneum, the saccus vaginalis,
which protrudes itself down the inguinal canal. By the fifth month the
lower part of the gubernaculum has become a thick cord, while the upper
part has disappeared. The lower part now consists of a central core of
unstriped muscle fiber, and outside this of a firm layer of striped
elements, connected, behind the peritoneum, with the abdominal wall. As
the scrotum develops, the main portion of the lower end of the
gubernaculum is carried, with the skin to which it is attached, to the
bottom of this pouch; other bands are carried to the medial side of the
thigh and to the perineum. The tube of peritoneum constituting the saccus
vaginalis projects itself downward into the inguinal canal, and emerges at
the cutaneous inguinal ring, pushing before it a part of the Obliquus
internus and the aponeurosis of the Obliquus externus, which form
respectively the Cremaster muscle and the intercrural fascia. It forms a
gradually elongating pouch, which eventually reaches the bottom of the
scrotum, and behind this pouch the testis is drawn by the growth of the
body of the fetus, for the gubernaculum does not grow commensurately with
the growth of other parts, and therefore the testis, being attached by the
gubernaculum to the bottom of the scrotum, is prevented from rising as the
body grows, and is drawn first into the inguinal canal and eventually into
the scrotum. It seems certain also that the gubernacular cord becomes
shortened as development proceeds, and this assists in causing the testis
to reach the bottom of the scrotum. By the end of the eighth month the
testis has reached the scrotum, preceded by the saccus vaginalis, which
communicates by its upper extremity with the peritoneal cavity. Just
before birth the upper part of the saccus vaginalis usually becomes
closed, and this obliteration extends gradually downward to within a short
distance of the testis. The process of peritoneum surrounding the testis
is now entirely cut off from the general peritoneal cavity and constitutes
the tunica vaginalis.
Descent of the Ovaries
In the female there is also a gubernaculum, which
effects a considerable change in the position of the ovary, though not so
extensive a change as in that of the testis. The gubernaculum in the
female lies in contact with the fundus of the uterus and contracts
adhesions to this organ, and thus the ovary is prevented from descending
below this level. The part of the gubernaculum between the ovary and the
uterus becomes ultimately the proper ligament of the ovary, while the part
between the uterus and the labium majus forms the round ligament of the
uterus. A pouch of peritoneum analogous to the saccus vaginalis in the
male accompanies it along the inguinal canal: it is called the canal of
Nuck. In rare cases the gubernaculum may fail to contract adhesions to the
uterus, and then the ovary descends through the inguinal canal into the
labium majus, and under these circumstances its position resembles that of
The Metanephros and the Permanent Kidney
The rudiments of the permanent kidneys make their
appearance about the end of the first or the beginning of the second
month. Each kidney has a two-fold origin, part arising from the
metanephros, and part as a diverticulum from the hind-end of the Wolffian
duct, close to where the latter opens into the cloaca. The metanephros
arises in the intermediate cell mass, caudal to the mesonephros, which it
resembles in structure. The diverticulum from the Wolffian duct grows
dorsalward and forward along the posterior abdominal wall, where its blind
extremity expands and subsequently divides into several buds, which form
the rudiments of the pelvis and calyces of the kidney; by continued growth
and subdivision it gives rise to the collecting tubules of the kidney. The
proximal portion of the diverticulum becomes the ureter. The secretory
tubules are developed from the metanephros, which is moulded over the
growing end of the diverticulum from the Wolffian duct. The tubules of the
metanephros, unlike those of the pronephros and mesonephros, do not open
into the Wolffian duct. One end expands to form a glomerulus, while the
rest of the tubule rapidly elongates to form the convoluted and straight
tubules, the loops of Henle, and the connecting tubules; these last join
and establish communications with the collecting tubules derived from the
ultimate ramifications of the diverticulum from the Wolffian duct. The
mesoderm around the tubules becomes condensed to form the connective
tissue of the kidney. The ureter opens at first into the hind-end of the
Wolffian duct; after the sixth week it separates from the Wolffian duct,
and opens independently into the part of the cloaca which ultimately
becomes the bladder. The secretory tubules of the kidney become arranged
into pyramidal masses or lobules, and the lobulated condition of the
kidneys exists for some time after birth, while traces of it may be found
even in the adult. The kidney of the ox and many other animals remains
lobulated throughout life.
The Urinary Bladder
The bladder is formed partly from the entodermal
cloaca and partly from the ends of the Wolffian ducts; the allantois takes
no share in its formation. After the separation of the rectum from the
dorsal part of the cloaca, the ventral part becomes subdivided into three
|| an anterior vesico-urethral portion, continuous
with the allantois—into this portion the Wolffian ducts open;
|| an intermediate narrow channel, the pelvic
|| a posterior phallic portion, closed externally
by the urogenital membrane.
The second and third parts together constitute the
urogenital sinus. The vesico-urethral portion absorbs the ends of the
Wolffian ducts and the associated ends of the renal diverticula, and these
give rise to the trigone of the bladder and part of the prostatic urethra.
The remainder of the vesico-urethral portion forms the body of the bladder
and part of the prostatic urethra; its apex is prolonged to the umbilicus
as a narrow canal, which later is obliterated and becomes the median
umbilical ligament (urachus).
The prostate originally consists of two separate
portions, each of which arises as a series of diverticular buds from the
epithelial lining of the urogenital sinus and vesico-urethral part of the
cloaca, between the third and fourth months. These buds become tubular,
and form the glandular substance of the two lobes, which ultimately meet
and fuse behind the urethra and also extend on to its ventral aspect. The
isthmus or middle lobe is formed as an extension of the lateral lobes
between the common ejaculatory ducts and the bladder. Skene’s ducts in
the female urethra are regarded as the homologues of the prostatic glands.
The bulbourethral glands of Cowper in the male, and
greater vestibular glands of Bartholin in the female, also arise as
diverticula from the epithelial lining of the urogenital sinus.
The External Organs of Generation
As already stated, the cloacal membrane, composed
of ectoderm and entoderm, originally reaches from the umbilicus to the
tail. The mesoderm extends to the midventral line for some distance behind
the umbilicus, and forms the lower part of the abdominal wall; it ends
below in a prominent swelling, the cloacal tubercle. Behind this tubercle
the urogenital part of the cloacal membrane separates the ingrowing sheets
The first rudiment of the penis (or clitoris) is a
structure termed the phallus; it is derived from the phallic portion of
the cloaca which has extended on to the end and sides of the under surface
of the cloacal tubercle. The terminal part of the phallus representing the
future glans becomes solid; the remainder, which is hollow, is converted
into a longitudinal groove by the absorption of the urogenital membrane.
In the female a deep groove forms around the
phallus and separates it from the rest of the cloacal tubercle, which is
now termed the genital tubercle. The sides of the genital tubercle grow
backward as the genital swellings, which ultimately form the labia majora;
the tubercle itself becomes the mons pubis. The labia minora arise by the
continued growth of the lips of the groove on the under surface of the
phallus; the remainder of the phallus forms the clitoris.
In the male the early changes are similar, but the
pelvic portion of the cloaca undergoes much greater development, pushing
before it the phallic portion. The genital swellings extend around between
the pelvic portion and the anus, and form a scrotal area; during the
changes associated with the descent of the testes this area is drawn out
to form the scrotal sacs. The penis is developed from the phallus. As in
the female, the urogenital membrane undergoes absorption, forming a
channel on the under surface of the phallus; this channel extends only as
far forward as the corona glandis.
The corpora cavernosa of the penis (or clitoris)
and of the urethra arise from the mesodermal tissue in the phallus; they
are at first dense structures, but later vascular spaces appear in them,
and they gradually become cavernous.
The prepuce in both sexes is formed by the growth
of a solid plate of ectoderm into the superficial part of the phallus; on
coronal section this plate presents the shape of a horseshoe. By the
breaking down of its more centrally situated cells the plate is split into
two lamellæ, and a cutaneous fold, the prepuce, is liberated and forms a
hood over the glans. "Adherent prepuce is not an adhesion really, but
a hindered central desquamation" (Berry Hart, op. cit.).
As already described, in both sexes the phallic
portion of the cloaca extends on to the under surface of the cloacal
tubercle as far forward as the apex. At the apex the walls of the phallic
portion come together and fuse, the lumen is obliterated, and a solid
plate, the urethral plate, is formed. The remainder of the phallic portion
is for a time tubular, and then, by the absorption of the urogenital
membrane, it establishes a communication with the exterior; this opening
is the primitive urogenital ostium, and it extends forward to the corona
In the female this condition is largely retained;
the portion of the groove on the clitoris broadens out while the body of
the clitoris enlarges, and thus the adult urethral opening is situated
behind the base of the clitoris.
In the male, by the greater growth of the pelvic
portion of the cloaca a longer urethra is formed, and the primitive ostium
is carried forward with the phallus, but it still ends at the corona
glandis. Later it closes from behind forward. Meanwhile the urethral plate
of the glans breaks down centrally to form a median groove continuous with
the primitive ostium. This groove also closes from behind forward, so that
the external urethral opening is shifted forward to the end of the glans.
Retrograde Pyelogram is a urologic procedure where
the physician injects contrast into the ureter in order to visualize the
ureter and kidney. The flow of contrast (up from the bladder to the
kidney) is opposite the usual flow of urine, hence the retrograde name.
Reasons for performing a retrograde pyelogram
include identification of filling defects (e.g. stones or tumors), as an
adjunct during the placement of ureteral stents or ureteroscopy, or to
delineate renal anatomy in preparation for surgery. Retrograde pyelography
is generally done when an intravenous excretory study (IVP or contrast CT
scan) cannot be done because of renal disease or allergy to intravenous
contrast. Relative contraindications include the presence of
infected urine, pregnancy and contrast allergy.
The procedure requires cystoscopy and the placement
of a small tube into the lower part of the ureter to inject contrast and
opacify the ureter and renal pelvis. Fluoroscopy, or dynamic X-Rays, is
typically used for visualization. The procedure is usually done under
general or regional anesthesia.
It is the historic medical practice of visually
examining a patient's urine for pus, blood, or other symptoms of disease.
It dates back to ancient Egypt, Babylon, and India. It was particularly
emphasized in Byzantine medicine.
By modern medical standards, Uroscopy is considered
to be a very limited means of obtaining evidence for the correct diagnosis
of a patient's condition. In addition, many of the assumptions made by
ancient physicians regarding uroscopy have proved to be quite incorrect
and unscientific. However, visual examination of a patient's urine may
provide preliminary evidence for a diagnosis, but is generally limited to
conditions that affect the urinary system (such as infection (turbidity)
or blood (infection or haemorrhage).
How Uroscopy Flask is Used
A uroscopy flask is a piece of glass that is
circular at the bottom, while there is a thin neck at the top, and on top
of that neck there is an opening for urine. In order for a doctor to
examine a patient's urine one would have to urinate into a uroscopy flask.
A uroscopy flask is a glass bottle that must be transparent. If there is
any color to the uroscopy flask, diagnosis could be wrong. In the process
of uroscopy, color is very crucial to find diseases. If the uroscopy flask
has a tint of color, the doctor may not be able effectively diagnose the
patient. The glass must also have an even thickness throughout the flask.
If the top is very thin glass and the bottom is thick glass, then the
impurities in the top may look different from the top and bottom. While in
all actuality they could be the very same impurities. The impurities in
urine have varying shapes, uneven glass will corrupt the diagnosis
The uroscopy wheel is a diagram that linked the
color of urine to a particular disease.
It usually has twenty different
uroscopy flasks with urine of different colors aligned around the boarder
of the circle. Each flask has a line that connects it to a summary of a
particular disease. This allowed doctors to have a quick reference guide
to twenty different types of urine.
Temperatue When Testing
The temperature at which the urine is examined is a
very important factor to consider in the process of uroscopy. When a
patient urinates, the urine will be warm, so it is necessary for it to
stay warm for proper evaluation. The external temperature should be the
same as the internal temperature. When the temperature of urine goes down
the bubbles in it will change. Some of them will disappear, but some will
remain. With the temperature decrease particles and impurities will be
more difficult to evaluate. They will toward the middle of the flask, then
sink to the bottom. They will all mix together, making it more difficult
to see the impurities.
Another problem with urine cooling is that it would
become thicker. The longer that it had to cool down the more likely it was
that the crystals in the it would bond together, causing it to thicken.
This could lead to a false diagnosis, that is why doctors usually
inspected the urine quickly.
Richard Bright in the 19th century A.D. invented a
technique that allowed doctors to examine a patients urine effectively
after the temperature had dropped. The process involved heating water,
then inserting the uroscopy flask containing cooled urine. This would heat
the urine causing the crystals that formed during loss of temperature to
break down. As a result the urine will become thin again. This process is
very effective, but it should be noted that a doctor should, "also be
careful not to shake them much before you inspect them for you will move
the particles and destroy the bubbles and dilute the deposits and confuse
the situation," (The Late Greco-Roman and Byzantine Contribution to
the Evolution of Laboratory Examinations of Bodily Excrement. Part1:
Urine, Sperm, Menses and Stools, Pavlos C. Goudas).
Lighting When Testing
Since the identifying the color of the urine is
essential for a proper diagnosis, the lighting is crucial. This is a very
complicated step in the uroscopy test. The doctor must can not visualy
examine the urine in an overly lit location, because it will make the
urine seem too bright. He can not examine the urine in a poorly lit
location, because he will not be able to properly see the urine. So, he
must examine the urine in both conditions. This is done to offset the
effects of not enough light and too much light. After he examines in both
conditions the doctor must use his best judgment, to make a diagnosis.
Common Urological Diseases
Disease in which the pancreas does not function
properly. Victims of this disease will have high glucose blood sugar.
Victims may suffer from: cardiovascular disease (doubled risk), chronic
renal failure (it is the main cause for dialysis in developed world
adults), retinal damage which can lead to blindness and is the most
significant cause of adult blindness in the non-elderly in the developed
world, nerve damage, erectile dysfunction (impotence), to gangrene with
risk of amputation of toes, feet, and even legs. Doctors would test by tasting the urine. If it was
sweet tasting then it meant the patient had diabetes.
Yellowish discoloration of the whites of the eyes,
skin, and mucous membranes caused by deposition of bile salts in these
tissues. It occurs as a symptom of various diseases, such as hepatitis,
that affect the processing of bile. Also called icterus.
Doctors would test by using their vision. If the
urine had a brownish tint then the patient would most likely have
The kidneys are supposed to filter wastes
(especially urea) from the blood and excrete them, along with water, as
urine. When they are not performing this task they patient is suffering
from kidney disease. The medical field that studies the kidneys and
diseases affecting the kidney is called nephrology, from the Ancient Greek
name for kidney.
Doctors would test urine using a visual
examination. If the urine was red and/or foamy the patient was suffering
from kidney disease.
"...and I also suffer chronic disease from my
kidneys for there are stones that come through the glands of my penis,
sometimes big like grams, only heavier, and have many shapes. And they are
polygonal and like pyramids or cubes. And because of the different shapes
they hurt the lumen of the urethra and cause extreme pains and sufferings.
And some other times when they are big enough they completely block my
urethra and I'm completely filled with liquids. And by tearing the lumen it
causes such pain, bringing death before my eyes..." (Johannes
Apokaukos, metropolitan of Naupaktos and Arta 1219AD)
Tumors of Urinary Tract
When a patient develops an uncontrolled, abnormal,
circumscribed growth of cells in the urinary tract.
Doctors would test urine by using a visual
examination. If the urine had blood in it the patient was suffering from
tumors in the urinary track.
Importance of Uroscopy
Uroscopy was important to the Roman and Byzantine
eras, because it allowed doctors to diagnose patients without technology.
This was an era in which there was no microscope, stethoscope, or even
thermometers. All that was needed was a uroscopy wheel, uroscopy flask,
and an experienced doctor to be able to give a diagnosis. It was a very
simple procedure that a doctor could determine a patients problem by
simply tasting and/or looking at their urine.
Uroscopy was also necessary, because the
Hippocratic Oath did not allow doctors to perform any type of surgery. It
stated "I will not cut for stone, even for patients in whom the
disease is manifest . . ." Doctors needed a
different way to find out the problems with their patients. That is when
the uroscopy test became involved. It followed the Hippocratic Oath and
was a very effective test for that particular time period.
Vasectomy is a permanent birth control method. In
some conventional clinics all or part of the vasa deferentia are
surgically removed, thus sterilizing the patient. In more modern clinics
and in no-scalpel (keyhole) vasectomies none of the vas is removed, but is
instead cut and sealed.
Vasectomy should not be confused with castration:
vasectomy does not involve removal of the testicles and it affects neither
the production of male sex hormones (mainly testosterone) nor their
secretion into the bloodstream. Therefore sexual desire (libido) and the
ability to have an erection and an orgasm with an ejaculation are not
affected. Because the sperm itself makes up a very small proportion of an
ejaculation, vasectomy does not significantly affect the volume,
appearance, texture or flavor of the ejaculate. Similarly, in females,
hormone production, libido, and the menstrual cycle are not affected by a
When the vasectomy is complete, sperm can no longer
exit the body through the penis. They are broken down and absorbed by the
body. Much fluid content is absorbed by membranes in the epididymis, and
much solid content is broken down by macrophages and re-absorbed via the
blood stream. Sperm is matured in the epididymis for about a month once it
leaves the testicles, and approximately 50% of the sperm produced never
make it to ejaculation in a non-vasectomized man. After vasectomy, the
membranes increase in size to absorb more fluid, and more macrophages are
recruited to break down and re-absorb more of the solid content.
Early failure rates of vasectomy are below 1%, but
the effectiveness of the operation and rates of complications vary with
the level of experience of the surgeon performing the operation and the
surgical technique used. Most men will experience minor bruising in the
scrotum for three to five days following the operation. Animal and human
data indicate that vasectomy does not increase atherosclerosis and that
increases in circulating immune complexes after vasectomy are transient.
The weight of the evidence regarding prostate and testicular cancer
suggests that men with vasectomy are not at increased risk of these
Although late failure (caused by recanalization of
the vasa deferentia) is very rare, it has been documented. Some sources
recommend yearly prostate examinations starting at an earlier age,.
Vasectomy is the most effective long-term
contraceptive method, and is among the safest options for family planning.
How popular sterilization is as a birth control method varies by age, with
men in their mid 30's to mid 40's being most likely to have a vasectomy.
The rate of vasectomies to tubal ligations worldwide is extremely
variable, and the statistics are mostly based on questionnaire studies
rather than actual counts of procedures performed. In the U.S. in 2005,
the CDC published state by state details of birth control usage by method
and age group. Overall, tubal ligation is ahead of vasectomy but not by a
large factor. In Britain vasectomy is more popular than tubal ligation,
though this statistic may be as a result of the data-gathering
Couples who opt for tubal ligation do so for a number of
|| Convenience of coupling the procedure with
delivery at a hospital.
|| Refusal of the man to undergo vasectomy due to
fear of possible side effects.
Couples who choose vasectomy are motivated by,
among other factors:
|| The lower cost and simplicity of vasectomy
|| Fewer complications
|| The lower mortality of vasectomy
|| Fear of surgery in the woman
|| Knowing men who have had the procedure and are
satisfied with the results
|| A stronger motivation for sterilization in the
Dependant on the clinic, patients may be
offered/given anti-anxiety medication (such as Xanax) approximately one
hour prior to the procedure. After the procedure, the patient may rest for
a short time, about 15-30 minutes. It is recommended that the patient be
driven home, mainly due to effects caused by the anti-anxiety medication
Ice should be placed over the dressing or gauze, at
the area of incision for 20 minutes each hour for the first 12 hours,
helping to reduce swelling and pain. The dressing or gauze should be kept
in place for several days to absorb any minor bleeding (bleeding should be
minimal). Anecdotal evidence highly supports faster recoveries for those
who follow the strict advice regarding rest and icing of the incision.
For the next 24-72 hours, the patient should remain
at home, sitting or lying for most of the time. Patients should not
shower, bathe, or wet the incision for 24 hours after the procedure.
Patients are typically advised not to operate a motor vehicle or engage in
moderate activity (such as climbing stairs more than necessary) for 72
hours. Patients may usually resume normal day-to-day activity after 72
hours but it is recommended that they wear scrotal support (can be found
in sporting goods stores) or normal supportive underwear (such as briefs
rather than boxer shorts) for one week. A light dressing is to be held in
place for up to one week. Sexual activity should be avoided for
approximately one week, but some physicians recommend resumption when
"comfortable". Of course, this varies from patient to patient
and their respective recovery rate. Vigorous exercise (especially bicycle
riding) should be avoided for two to four weeks. After four weeks, the
patient is typically clear to resume all normal activities. In some cases
pain in the testicles can last past four weeks, maybe even years. This
side effect is not well understood. Some men have to undergo further
surgery to reduce the pain. Typically removal of the epididymis, removal
of the testicle(s) or in some cases reversal of the vasectomy is employed
to lessen the pain.
Although men considering vasectomies should not
think of them as reversible, and most men and their spouses are satisfied
with the operation, there is a procedure to reverse vasectomies using
vasovasostomy (a form of microsurgery). It is, however, not effective in
all cases, with the success rate depending on such factors as the method
used for the vasectomy and the length of time that has passed since the
vasectomy was performed. There is evidence that men who have had a
vasectomy produce abnormal sperm, which would explain why even a
mechanically successful reversal does not always restore fertility.
In one study, vasectomy reversal was found to be
75% effective for reducing the symptoms of chronic post-vasectomy pain.
In order to allow a possibility of reproduction
(via artificial insemination) after vasectomy, some men opt for
cryostorage of sperm before sterilization, and although the long term
viability of spermatozoa in cryostorage is questionable,
some experts advise that this be done before vasectomy.
Various temporary male contraceptives are being
researched but not yet available, such as male hormonal contraceptives and
the intra vas device. There has been at least one documented case of a
vasectomy being reversed on a dog, which then fathered puppies after the
In the UK, Vasectomy is often available free of
charge through the National Health Service upon referral by one's GP.
However, some PCTs do not fund the procedure and patients may have to
obtain a vasectomy privately. There are also private clinics (such as
Marie Stopes International) who perform the operation with shorter waiting
Chronic Post-Vasectomy Pain
The incidence of chronic post-vasectomy pain is
estimated to be less than 10% depending on the severity of pain that
qualifies for the particular study. While the evidence of post vasectomy
pain (PVP) is strong, it should not currently be made a major
consideration when choosing to have a vasectomy.
A recent study by John Guillebaud on 5000 patients
studying the effects of PVP confirmed the evidence quoted above. However,
it also showed that the background risk of testicular pain in the general
(non vasectomized) population is 10%. All 5000 patients when asked in
questionnaires following the procedure said they would have a vasectomy
again as benefits outweighed the risks.
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