Urology disorders
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I now have rich content from Smith and Tanagho's General Urology, 19th Edition and Campbell Walsh Wein Urology. Let me compile a comprehensive overview.
Major Urology Disorders — Medical Student Overview
Based on Smith and Tanagho's General Urology, 19th Edition & Campbell Walsh Wein Urology, 3-Volume Set
1. Urinary Tract Infections (UTIs)
Definition: Infection of the urinary tract, classified as uncomplicated (lower tract, community-acquired in healthy women) or complicated (upper tract, structural/functional abnormality, or in special populations).
Classification:
- Cystitis — bladder infection; dysuria, frequency, urgency, suprapubic pain
- Pyelonephritis — upper tract infection; flank pain, fever, costovertebral angle (CVA) tenderness, nausea/vomiting
- Prostatitis — see below
- Urosepsis — systemic sepsis originating from a urinary source; fever + obstruction = urologic emergency requiring immediate decompression (retrograde ureteral stent or percutaneous nephrostomy)
Key pathogens: E. coli (most common), Klebsiella, Proteus, Pseudomonas, Enterococcus
Diagnosis: Urinalysis (pyuria, bacteriuria, nitrites), urine culture and sensitivity
Treatment: Uncomplicated cystitis → nitrofurantoin or TMP-SMX; pyelonephritis → fluoroquinolones or 3rd-gen cephalosporins; adjust based on culture results
"Fever associated with urinary tract obstruction requires prompt decompression." — Smith and Tanagho's General Urology
2. Urolithiasis (Kidney Stones / Nephrolithiasis)
Epidemiology: Common; ~12% lifetime risk in men, 7% in women. Recurrence rate ~50% at 5 years.
Stone Types & Associations:
| Stone Type | % | Key Feature |
|---|---|---|
| Calcium oxalate/phosphate | 80% | Most common; radiopaque |
| Struvite (magnesium ammonium phosphate) | 10–15% | Infection stones; urease-producing organisms (Proteus, Klebsiella); staghorn calculi |
| Uric acid | 5–8% | Radiolucent; associated with gout, low urine pH |
| Cystine | 1–3% | Hereditary cystinuria; hexagonal crystals on UA |
Clinical Features: Renal colic — sudden, severe flank/loin-to-groin pain, nausea/vomiting, hematuria. Pain is colicky due to ureteral peristalsis against obstruction.
Special situations:
- Pregnancy: Renal colic is the most common nonobstetric cause of acute abdominal pain (~1:1500 pregnancies). Avoid radiation; US is first-line imaging; ~90% of symptomatic calculi pass spontaneously
- Transplant recipients: Classic colic absent (denervated kidney); may mimic rejection
- Stone + fever = emergency — obstructed infected system; urgent decompression required
Diagnosis: Non-contrast CT (gold standard); KUB (plain film); renal US (esp. in pregnancy)
Management:
- Small stones <5 mm: expectant (90% pass spontaneously)
- Medical expulsive therapy: alpha-blockers (tamsulosin)
- Larger stones/failed conservative Rx: ESWL, ureteroscopy, percutaneous nephrolithotomy (PCNL) for staghorn calculi
3. Benign Prostatic Hyperplasia (BPH)
Pathophysiology: Nodular hyperplasia of periurethral/transition zone of prostate → bladder outlet obstruction (BOO). Mediated by dihydrotestosterone (DHT). Affects nearly all men by age 80.
Symptoms — Lower Urinary Tract Symptoms (LUTS):
- Obstructive: hesitancy, weak stream, straining, incomplete emptying, post-void dribbling, urinary retention
- Irritative: frequency, urgency, nocturia, dysuria
Diagnosis: IPSS (International Prostate Symptom Score), DRE, PSA (to exclude cancer), uroflowmetry, post-void residual (PVR), urodynamics if needed
Treatment:
- Mild (IPSS <8): watchful waiting
- Moderate-severe:
- Alpha-blockers (tamsulosin, alfuzosin) — rapid symptom relief
- 5-alpha reductase inhibitors (finasteride, dutasteride) — reduce gland volume; combination therapy more effective than monotherapy
- PDE5 inhibitors (tadalafil) — for LUTS + erectile dysfunction
- Surgical: TURP (gold standard), laser vaporization (PVP), prostatic artery embolization (PAE) for large prostates >90g or high surgical risk
4. Prostate Cancer
Epidemiology: Most common male cancer (excluding skin). Predominantly adenocarcinoma of the peripheral zone.
Staging: Gleason score/Grade Group system; TNM staging; PSA level
Diagnosis:
- PSA screening (controversial; no universal recommendation for transplant recipients)
- DRE
- Novel urine markers: PCA3 (noncoding RNA, FDA-approved for repeat biopsy decisions), TMPRSS2:ERG fusion (associated with aggressive disease)
- Transrectal ultrasound (TRUS)-guided biopsy → MRI-fusion biopsy increasingly used
Management by stage:
| Stage | Options |
|---|---|
| Localized (low-risk) | Active surveillance, radical prostatectomy, radiation therapy |
| Localized (intermediate/high-risk) | Surgery ± adjuvant RT; RT + androgen deprivation therapy (ADT) |
| Metastatic | ADT (GnRH agonists/antagonists ± anti-androgens), docetaxel/abiraterone/enzalutamide for mCRPC |
Prognosis: Localized disease: >95% 10-year survival; metastatic castration-resistant prostate cancer (mCRPC): median survival ~3 years
5. Renal Cell Carcinoma (RCC)
Epidemiology: Most common renal malignancy in adults; M:F = 2:1; peak 6th–7th decade. Incidence ↑ in transplant recipients (4.6% of post-transplant cancers vs. 3% general population).
Subtypes:
- Clear cell (70–75%) — associated with VHL gene mutation; most aggressive
- Papillary (10–15%) — types 1 and 2; most common in transplanted kidneys (56%)
- Chromophobe (5%) — best prognosis
Classic triad (rare today): Hematuria + flank pain + palpable mass → usually advanced disease
Diagnosis: Incidental finding on US/CT (most common); CT is definitive. Staging by CT chest/abdomen/pelvis.
Management:
- Localized: Partial or radical nephrectomy; ablation (cryotherapy, RFA) for small tumors
- Advanced/metastatic: Targeted therapy (sunitinib, pazopanib, cabozantinib); immunotherapy (nivolumab + ipilimumab); mTOR inhibitors
6. Bladder Cancer
Epidemiology: M:F = 3:1; strong association with smoking (most important risk factor) and occupational exposure to aromatic amines. Risk is significantly elevated post-renal transplant (SIR ≈ 3.18).
Histology: 90% transitional cell carcinoma (urothelial); squamous cell (associated with Schistosoma haematobium); adenocarcinoma (rare)
Clinical Features: Painless hematuria is the cardinal symptom. Irritative voiding symptoms in carcinoma in situ (CIS).
Urine Tumor Markers (sensitivity/specificity):
| Test | Sensitivity | Specificity |
|---|---|---|
| Cytology | ~40% | >90% |
| NMP22 | 68% | 79% |
| UroVysion FISH | 76% | 85% |
| ImmunoCyt | 84% | 75% |
| Telomerase | 75% | 86% |
Staging (determines treatment):
- Non-muscle invasive (NMIBC, Ta, T1, Tis): TURBT + intravesical BCG or mitomycin C; surveillance cystoscopy
- Muscle-invasive (MIBC, T2–T4): Neoadjuvant cisplatin-based chemotherapy + radical cystectomy (gold standard); bladder-sparing trimodality therapy for selected patients
7. Testicular Cancer
Epidemiology: Most common solid tumor in men ages 20–35; ~95% germ cell tumors (GCTs)
Classification:
- Seminoma — homogeneous, radiosensitive; never elevates AFP
- Non-seminomatous GCTs (NSGCTs) — teratoma, embryonal, choriocarcinoma, yolk sac tumor; may elevate AFP ± β-hCG
Tumor Markers (critical for staging & monitoring):
| Marker | Half-life | Elevated in |
|---|---|---|
| AFP | 5–7 days | NSGCTs only (NEVER seminoma) |
| β-hCG | 24–36 hours | Both (7% of seminomas; up to 100% in choriocarcinoma) |
| LDH | — | Advanced disease (all types) |
Risk classification (IGCCCG):
| Risk | Nonseminoma | Seminoma |
|---|---|---|
| Good | Testicular/retroperitoneal primary, S1 markers, no nonpulmonary visceral mets | Any primary, no nonpulmonary visceral mets |
| Intermediate | S2 markers | Any primary (never poor risk) |
| Poor | Mediastinal primary OR nonpulmonary visceral mets OR S3 markers | None |
Management: Radical inguinal orchiectomy → staging CT → stage-dependent treatment
- Seminoma stage I → surveillance or RT; stage II–III → BEP chemotherapy
- NSGCT stage I → surveillance or RPLND; stage II–III → BEP ± RPLND
Prognosis: Excellent overall — stage I: 98–100% 5-year disease-free survival; good-risk metastatic: >90%
8. Neurogenic Bladder
Definition: Bladder dysfunction due to neurological disease at any level (suprapontine, pontine, spinal cord, peripheral).
Types:
- Overactive (spastic/UMN): Detrusor overactivity, urgency incontinence; suprasacral lesions (stroke, MS, SCI above T6)
- Underactive (flaccid/LMN): Detrusor areflexia, overflow incontinence; sacral/peripheral lesions (DM, pelvic surgery, cauda equina)
- Detrusor-sphincter dyssynergia (DSD): High-pressure voiding → upper tract damage; suprasacral SCI
Diagnosis: Urodynamics (UDS) is the gold standard — evaluates storage and voiding phases; essential in neurologic patients even without symptoms to assess for silent upper tract damage
Treatment: Clean intermittent catheterization (CIC) as cornerstone; antimuscarinics (oxybutynin, solifenacin) or beta-3 agonist (mirabegron) for overactive bladder; botulinum toxin intravesical injection; sacral neuromodulation
9. Urinary Incontinence
| Type | Mechanism | Classic Presentation |
|---|---|---|
| Stress | Inadequate sphincter support | Leakage with cough/sneeze/exercise |
| Urge (OAB) | Detrusor overactivity | Sudden urge → leakage before reaching toilet |
| Mixed | Combination | Both triggers |
| Overflow | Chronic retention/detrusor failure | Constant dribbling; large PVR |
| Functional | Cognitive/mobility impairment | Normal LUT, cannot reach toilet |
Management: Behavioral therapy, pelvic floor exercises (Kegel), antimuscarinics, beta-3 agonists; surgical: mid-urethral sling (stress), artificial urinary sphincter (post-prostatectomy incontinence)
10. Male Infertility
Causes (Azoospermia framework):
- Pre-testicular (2%): Hypogonadotropic hypogonadism — GnRH/LH/FSH deficiency (Kallmann syndrome, pituitary tumor, prolactinoma)
- Testicular (75%): Spermatogenic failure — maturation arrest, Sertoli cell-only, varicocele (most common surgically correctable cause), cryptorchidism, Y-chromosome microdeletions (AZFa, AZFb, AZFc), Klinefelter syndrome
- Post-testicular (5%): Obstructive azoospermia — congenital bilateral absence of vas deferens (CBAVD, associated with CFTR mutations), vasectomy, epididymal obstruction
Diagnosis: Semen analysis ×2; FSH/LH/testosterone; karyotype if indicated; testicular biopsy; TESE/MESA for sperm retrieval
11. Erectile Dysfunction (ED)
Pathophysiology: Erection mediated by NO → cGMP → smooth muscle relaxation → cavernosal arterial inflow. Loss of NO signaling (vascular), neurogenic damage, or hormonal causes underlie ED.
Key Risk Factors: DM, HTN, dyslipidemia, smoking, depression, pelvic surgery/radiation, hypogonadism
Treatment:
- PDE5 inhibitors (sildenafil, tadalafil, vardenafil) — first-line; contraindicated with nitrates
- Vacuum erection device
- Intracavernosal alprostadil injection
- Penile prosthesis (refractory cases)
Quick Reference Summary Table
| Disorder | Cardinal Sign | Key Investigation | First-line Rx |
|---|---|---|---|
| UTI/Cystitis | Dysuria, frequency | UA, urine culture | TMP-SMX / nitrofurantoin |
| Pyelonephritis | Fever, flank pain | UA, urine culture, CT | IV antibiotics |
| Nephrolithiasis | Renal colic, hematuria | Non-contrast CT | Analgesia, alpha-blocker, watchful waiting |
| BPH | LUTS (obstructive + irritative) | IPSS, uroflowmetry, PVR | Alpha-blocker ± 5-ARI |
| Prostate cancer | Elevated PSA, BOO | TRUS/MRI biopsy | Surveillance / surgery / RT / ADT |
| RCC | Painless hematuria, flank mass | CT abdomen | Nephrectomy ± targeted therapy |
| Bladder cancer | Painless hematuria | Cystoscopy + TURBT | TURBT + intravesical BCG (NMIBC) |
| Testicular cancer | Firm, painless testicular mass | AFP, β-hCG, LDH, testicular US | Radical inguinal orchiectomy |
| Neurogenic bladder | Incontinence / retention | Urodynamics | CIC ± antimuscarinics |
| Male infertility | Azoospermia/oligospermia | Semen analysis, hormones | Depends on cause |
Sources: Smith and Tanagho's General Urology, 19th Edition; Campbell Walsh Wein Urology, 3-Volume Set
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