Urinary And Urethra Tract Infection Interstitial Cystitis Of The Bladders Notes

Urinary Bladder And Urethra

Surgical Anatomy Of The Bladder

Lining Epithelium:

• The urinary bladder is lined by transitional epithelium (urothelium) that lies over the lamina propria (connective tissue).
• Bladder cancers are transitional cell carcinomas.

Read And Learn More: Surgery of Urology Notes

• However, due to metaplastic changes in the epithelium caused by chronic irritation (e.g. from a stone), other malignancies, such as squamous cell carcinoma, can occur.
• Bladder cancer can easily spread through the lamina propria into the muscle coat (detrusor muscle).

Detrusor Muscle:

It is a smooth muscle with intertwined fibres. Therefore, in bladder neck obstruction, it hypertrophies and leads to morphological alterations, such as trabeculations/ sacculations.

Trigone:

It is a triangular area that lays between the internal urethral orifice (bladder neck) inferiorly and the orifices of the ureter laterally. It is the most sensitive part of the bladder, and its irritation leads to increased urinary frequency and strangury.

Bladder Neck:

• The internal sphincter is a smooth muscle that surrounds the bladder neck. It is innervated by α-adrenergic fibres and prevents retrograde ejaculation of urine.
• The distal urethral sphincter is a somatic striated muscle supplied by S2–S4 via the pudendal nerves.

Supports of the Bladder:

• Posteriorly, the endopelvic fascia, which is continuous with the lateral ligaments of the rectum, need to be divided during radical cystectomy.
• Anteriorly, the puboprostatic ligaments need to be divided during radical cystectomy.
• False ligaments: The urachus and obliterated hypogastric arteries, together with the fold of the peritoneum overlying these structures, are called false ligaments (medial ligaments). Peritoneal folds raised by the inferior epigastric arteries are called lateral ligaments.

Blood Supply:

• The superior and inferior vesical arteries, which are derived from the anterior trunk of the internal iliac artery, are the main source of arterial blood supply. Minor blood supply comes from the obturator and inferior gluteal arteries and, in females, from the uterine and vaginal arteries as well.
• Veins form a plexus on the lateral and inferior surfaces of the bladder. Hence, during suprapubic cystostomy, these structures have to be avoided while entering the bladder.
• The vesical plexus, which is continuous with the prostatic plexus of veins in males, drains into the internal iliac vein.

Lymphatics:

• Internal iliac nodes are the first level of lymph nodes.
• The obturator and external iliac lymph nodes get involved later.

Innervation:

• Parasympathetic supply comes from the anterior divisions of the sacral nerves (S2, S3, S4) through the inferior hypogastric plexus. Following excision of the rectum, disturbance of micturition and sexual function may occur due to damage to the pelvic plexus.
• Sympathetic supply comes from T10–L2.

Vesical Calculus

• Primary: Stones which develop in sterile urine in the absence of bladder pathology. These also include renal stones that have migrated to the bladder.
• Secondary: Stones develop in the presence of infection and stasis due to urinary flow obstruction. They develop secondary to bladder outlet obstruction.

Types:

1. Oxalate stone: Moderate size, uneven surface. Mulberry stones are dark brown or black due to the presence of blood pigment. These are usually found in the kidneys.
2. Uric acid stones: They are the most common type of urinary bladder stones. Round to oval, smooth, pale yellow, not opaque on X-rays. They are usually formed in the bladder.
3. Cystine: Radiopaque due to high sulphur content.
4. Triple phosphate: These stones comprise ammonium, magnesium, and calcium phosphates. They occur in urine infected with urea-splitting organisms. Sometimes, they grow rapidly. The nucleus of the stone may contain bacteria, desquamated epithelium, or a foreign body. They are dirty white in colour.
5. Jackstones: Vesical calculi with jagged/spiculated surfaces.
6. In malnourished children <10 years of age, ammonium urate and calcium oxalate stones are found.

Clinical Features:

• Males are affected 8 times more frequently than are females.
• Frequency of micturition is the earliest symptom due to cystitis.
• Pain at the end of micturition referred to the tip of the penis in young boys suggests bladder stone. In school-going children, pain is aggravated by jumping and jolting. Pain is decreased on lying down because the stone falls away from the trigone of the bladder. Typically, oxalate stones produce pain. Painful ineffective micturition is described as strangury.
• Haematuria occurs if the stone causes abrasions in the bladder mucosa.
• Acute retention of urine is due to the calculus obstructing the internal meatus.

Investigations:

• Urine: Red blood cells may be present—microscopic haematuria
• Envelope-like crystals: Oxalate stone
• Hexagonal plates: Cystine stone
• Radiography: In 90% of cases, the stone is visible. However, it is important to look for stones in the entire urinary tract.
• Cystoscopy: It is the best confirmatory investigation. The stone can be visualised.
• A click can be heard when the stone comes into contact with the instrument.

Treatment

• Ultrasound lithotripsy—very safe, but only for small stones.
• Laser lithotripsy (holmium laser)—can break most large stones.
• Percutaneous suprapubic litholapaxy—using needle, guidance, and metal dilators.

1. Litholapaxy:

• By introducing a cystoscopic lithotrite, the stone is firmly grasped and broken up. Small fragments of the stone are evacuated with an evacuator.

Contraindications for litholapaxy:

1. Urethra: Obstruction such as stricture, enlarged prostate.

2. Bladder: Cystitis, contracted bladder, carcinoma.

2. Suprapubic Cystolithotomy:

• Can be done when the stone is too big, too hard to crush, or too soft.
  • Transitional cell carcinoma—90%
  • Squamous cell carcinoma—5–10%
  • Adenocarcinoma—2%

Carcinoma Of The Bladder

Aetiology:

• Incidence is more in aniline dye workers. Products such as benzidine and 3-naphthylamine are carcinogeni
• It is more common in men and in smokers (most common cause— >50% of cases).
• Chronic irritation by stones or a catheter may also produce carcinoma: 95% of tumours originate in the mucous membrane.
• Bilharziasis or schistosomiasis increases the risk of bladder cancer (squamous cell carcinoma).
• Congenital anomalies associated with an increased risk of carcinoma bladder:
  • Patent urachus
  • Exstrophy bladder
  • Bladder diverticuli (can give rise to squamous cell carcinoma).

Pathology:

1. Malignant villous tumours: They are transitional cell carcinomas. Multiple primaries are found in 25% of patients with bladder cancer.
   1. The villi are stunted, swollen, slow-growing, and resemble a cauliflower (verrucous).
   2. They may be sessile if high-grade.
   3. The bladder wall is more vascular.
   4. Submucous lymph nodes appear around the growth.
2. Solid tumours are always malignant: They are sessile and lobulated.
3. Carcinomatous ulcer: It arises in leukoplakia.

Histological Types:

1. Transitional cell carcinoma—90% of tumours. The trigone and posterior bladder wall are affected.
2. Squamous cell carcinomIs seen in 5–10% of patients. The lateral wall and dome are involved.
3. Adenocarcinoma arises from urachal remnants and urethral glands–-seen in 2% of patients. It occurs in conduits, pouches, etc.
4. Mixed variety
5. Undifferentiated

Clinical Features

• In 90% of cases, the initial symptom is painless, intermittent haematuria.
• Severe cystitis-like symptoms occur in carcinomatous ulcer.
• Later, painful, blood-stained micturition may occur.
• Strangury: Painful micturition with bleeding and incomplete emptying of the bladder.
• Loin pain is due to ureteric obstruction with hydronephrosis.
• Suprapubic pain, groin pain, and perineal pain are due to nerve infiltration. This indicates advanced nature of the growth.
• The most common site of lymph node metastasis is the pelvic (obturator) lymph nodes, and the most common site of visceral metastasis is the liver.

Investigations:

1. Urine: Cytology of 3 freshly-voided samples.

2. IVU: To detect a filling defect in the bladder.

3. Ultrasound to can detect bladder carcinoma and liver metastasis.

4. CECT scan is the investigation of choice, especially to know the spread of disease (Figs 58.6–58.9).

• It is especially useful to know the infiltration of the muscle, perivesical tissue, prostate, and pelvic wall.

5. Cystoscopy: It is the gold standard investigation to locate the lesion and take a biopsy for further management.

6. Bimanual palpation, rectoabdominally in males and vaginoabdominally in females, is done under general anaesthesiThickening of the bladder wall, mobility, fixity, and hardness can be made out.

7. Tumour markers: Urinary markers—BTA and NMP22.

Staging of Bladder Cancer:

1. Clinical staging: Jewett, Strong and Marshall system

• Clinically, the tumours are broadly classified into three groups: superficial/noninvasive, infiltrating/ invasive, and carcinoma in situ.

2. TNM staging

Treatment of Carcinoma Urinary Bladder:

1. Carcinoma not involving the muscle layer (Tis Ta, T1):

1. Transurethral resection of the tumour (resected base to be screened for the tumour by microscopy).
2. Postoperative intravesical chemotherapy with thiotepa/adriamycin/mitomycin retained inside the bladder for 1 hour: 6–8 courses at weekly intervals to reduce recurrence.
3. BCG or interferon immunotherapy is given postoperatively intravesically to prevent tumour recurrence.

2. T2–T4 lesions: Radical cystectomy followed by systemic chemotherapy (MVAC: Methotrexate, vinblastine, adriamycin, cisplatin). Radical cystectomy: Removal of the bladder with pericystic fat, prostate, seminal vesicles, and urethra in men, and the bladder with pericystic fat, cervix, uterus, anterior vaginal vault, urethra, and ovaries in women. It is a major surgery with a 3–8% mortality rate.

3. Any T, N1, M0 or any T, N0, M1—systemic chemotherapy (MVAC) followed by radiation therapy or surgery should be done.

4. Small lesion involving muscles in the vault of the bladder or posterolateral wall of the bladder: Partial cystectomy (segmental resection) of the part of the bladder containing the growth with a wide margin of 2–3 cm. This should be followed by intravesical chemotherapy.

Role of Radiotherapy:

1. Local: If the lesion is not anaplastic and is ≤ 4 cm after open diathermy excision, radiotherapy can be given.

• Implantation of radioactive Gold grains—198Au
• Radioactive Tantalum wire—192Ta

2. Deep X-ray therapy:

• Indication: Undifferentiated carcinoma
• By using Cobalt 60 or linear accelerator.

Exstrophy Of The Bladder (Ectopia Vesicae)

• A rare congenital anomaly seen in 1:50,000 births
• Male:Female = 4:1

Aetiopathogenesis

This occurs due to failure of development of the lower abdominal wall and anterior wall of the urinary bladder.

As a result, the posterior bladder wall is seen protruding out below the umbilicus. Hence, it is exstrophy of the bladder.

Types

1. Complete: Pubic symphysis is not formed, complete epispadias in male or bifid clitoris in females.
2. Incomplete: Pubic symphysis and penis/clitoris are normal.

Clinical Features:

• More common in male children.
• The posterior bladder wall is seen in the lower abdomen as a pink to red mucosa and is partially inflamed.
• Umbilicus is usually absent.
• Penis is rudimentary, and epispadias may be present.
• Testis descends normally into a well-developed scrotum.
• Pubic symphysis is widely separateIt has an advantage in female patients in that it facilitates delivery.
• In female children—umbilicus is absent, external genitalia are poorly developed, and the clitoris is bifi
• Constant dribbling of urine outside—therefore, patients smell of urine.
• Recurrent urinary tract infection (UTI).
• Rectal prolapse may be present.

Complications

1. Renal failure due to recurrent UTI.
2. Adenocarcinoma of the bladder at an early age.
3. Ammoniacal dermatitis of the skin.

Treatment:

1. Early presentation (neonatal or infancy): Reconstruction of the anterior wall of the bladder with reconstruction of the bladder sphincter (enterocystoplasty).

2. Complete: Total cystectomy with urinary diversion by implantation of the ureters in the sigmoid colon (ureterosigmoidostomy) followed by reconstruction of the anterior abdominal wall if the patient has urinary incontinence.

Acute Cystitis—Urinary Tract Infection (UTI)

Aetiology and Pathogenesis:

Acute uncomplicated bacterial cystitis predominantly affects women. By definition, these infections occur in the absence of any anatomic or functional abnormality of the urinary tract. The ascending faecal–perineal–urethral route is the primary source of infection. Men are somewhat protected from ascending infection because of their long urethra and the antibacterial properties of prostatic secretions.

Causative Organisms 80% of bladder infections in women are caused by E. coli followed by other gram-negative organisms such as Klebsiella and Proteus species.

Clinical Features:

Irritative voiding symptoms (frequency, urgency, dysuria) are the hallmarks of cystitis. Low backache and suprapubic pain are other complaints. Fever and other constitutional symptoms are usually present. Physical examination is frequently unremarkable, except for suprapubic tenderness.

Diagnosis:

• Urinary microscopy is the mainstay of diagnosis. Diagnosis is strongly considered positive if microscopy shows >5 WBCs/high power field in females and 2–3 WBCs/high power field in males.
• Urine culture not only confirms the diagnosis but also identifies the causative organisms.
• Other tests and imaging studies are not indicated in uncomplicated infections, unless the patient presents with recurrent episodes.

Management:

• Antibiotic therapy for a period of 7–10 days based on the culture and sensitivity report.
• Symptomatic treatment in the form of antipyretics, urinary analgesics, and antispasmodics may help.

Diverticula Of The Bladder

Types:

• Congenital (situated midline anterosuperiorly): Rare and usually asymptomatiThey represent the unobliterated vesical end of the urachus. It may require excision, if chronic infection persists.
• Acquired: They are pulsion diverticula and occur due to bladder outflow obstruction. Intravesical pressure is > 150 cm H 2O.

Pathology:

• The diverticulum is lined by bladder mucosa.
• The opening (mouth) is situated above and to the outer side of one ureteric orifice.

Clinical Features

• Most common in males (95%) > 50 years of age.
• Symptoms of recurrent urinary infection: Suprapubic pain, frequency of micturition, fever with chills, etc.
• Symptoms of lower urinary obstruction: Frequency, urgency, hesitancy, etc.
• Symptoms of pyelonephritis: Backache, fever, renal angle tenderness, et

Investigations:

1. Cystoscopy: Full bladder distension is necessary to search for diverticulum.
2. Intravenous urography: It can detect the site of diverticulum and hydronephrosis.
3. Ultrasonography
   • It can detect residual urine.
   • It can detect diverticulum.
   • It can detect associated stone(s)

Treatment:

• Combined intravesical and extravesical diverticulectomy is done if complications are present.
• Asymptomatic patients are advised to void the urine twice (double voiding).

Urinary Fistulae

Introduction

Urinary fistulae are not an uncommon problem encountered by surgeons. They are broadly classified into congenital and acquireCongenital causes are a few, which are discussed in more detail in their respective chapters. Acquired fistulae are more important and are discussed below. Among these, vesicovaginal fistula is discussed in more detail.

Acquired Fistulae:

1. Traumatic Urinary Fistula Perforating wounds, penetrating wounds, or following pelvic surgery.
2. Vesicovaginal Fistula

Causes

• Protracted or neglected labour
• Gynaecological operations like total hysterectomy and anterior colporrhaphy
• Radiation causing avascular necrosis of the bladder
• Carcinoma cervix infiltrating the bladder.

Clinical features:

• Leakage of urine from the vagina
• Excoriation of the vulva

Diagnosis:

• Digital vaginal examination may reveal thickening on the anterior wall of the vagina.
• Vaginal speculum examination: Dribbling of urine into the vagina.
• Swab test: Methylene blue is injected into the urethrIf the vaginal swab is coloured blue, it is a vesicovaginal fistula.

Treatment:

• Low fistula: Transvaginal repair
• High fistula: Suprapubic approach and repair (Modified O’Connor’s repair).

3. Fistula from Renal Pelvis to Skin or Gut

• Tuberculosis causes caseation and may result in a fistula in the loin.
• Large staghorn calculi
• Pyonephrosis
• Crohn’s disease of the renal pelvis.

Interstitial Cystitis

• It was first described by Guy Hunner (gynaecologist) in 1914 (hence, called Hunner’s ulcer). It is also called as bladder pain syndrome.
• Initial symptoms are increased frequency and pain. Pain is relieved by micturition and is aggravated by overdistension of bladder.
• The characteristic linear bleeding ulcer is caused by the splitting of mucosa when the bladder is distended under anaesthesia.
• It is common in Western female patients. Many are psychiatric patients.
• There is severe fibrosis of the urinary bladder due to pancystitis, which results in a small thimble bladder. (In India, tuberculosis must be considered.) The capacity of such urinary bladder to store urine is about 30–60 ml.
• Frequency of micturition and pain due to decreased bladder capacity are the features. It causes sterile pyuria.
• Cystoscopy and biopsy confirm the diagnosis.
• Treatment is difficult—hydrostatic dilatation, instillation of dimethyl sulphoxide, or surgical procedures such as ileocystoplasty have been trie

Schistosoma Haematobium

• It is the most common cause of calcification in the bladder wall.
• It is called urinary bilharziasis.
• The disease is caused by embryos (cercariae) of schistosoma, which enter the body by penetrating the skin and reaching the bladder via the portal vein in a retrograde manner. In the bladder, ova are released and excreted back into fresh water via the urine. Fresh water snail is the intermediate host.
• Multiple pseudotubercles, nodules, granulomas, and fibrosis are the prominent pathological features.
• Diagnosis is suspected by painless terminal haematuria, which lasts for 5 days. Itchy skin papules are one of the early manifestations of schistosomiasis. It is known as cercarial dermatitis. Katayama fever refers to fever, itching, splenomegaly, and hepatomegaly during acute schistosomiasis.
• Cystoscopy and biopsy confirm the diagnosis.
• It is treated by long-term praziquantel, and surgery (ileocystoplasty) may be required.

Urinary Diversion

Patients with lower urinary tract cancers or severe functional or anatomic abnormalities of the urinary bladder may require urinary diversion.

The most common method of urinary diversion incorporates various intestinal segments into the urinary tract. Virtually every segment of the intestinal tract is used.

1. Ileal conduit: 18–20 cm of the ileum is used as a conduit. Ureters are directly implanted into it. The end of the ileal conduit is brought through the lateral aspect of the rectus abdominis muscle, and a stoma is made. This simply acts as a conduit carrying urine from the renal pelvis or ureter to the skin, where urine is collected in an appliance attached to the skin surface. It is not a continent mechanism.
2. Ureterosigmoidostomy is an example of a continent urinary reservoir, wherein the ureters are anastomosed into the sigmoid colon. The most worrisome complication of this procedure is the development of adenocarcinoma at the site of ureter implantation.
   • Routine sigmoidoscopy is recommended annually after 5 years of the procedure.
   • A newer method of continent diversion—orthotopic bladder substitution.
3. Nephrostomy: It is required for drainage and decompression of the upper urinary tract and is indicated in the following situations:
   • Retrograde ureteral catheterisation is not advisable (e.g. in sepsis secondary to ureteral obstruction).
   • Retrograde ureteral catheterisation is impossible (e.g. complete ureteral obstruction by stone, tumour, or stricture).
   • It is done by a percutaneous approach.
4. Ureteroureterostomy: It is the anastomosis of the ureter to the ureter following resection. It can be on the same side if the resection length of the ureter is ≤4 cm or to the opposite ureter if the resection length is >4 cm.

Indications:

1. Trauma to the ureter
2. Ureteric involvement by neoplastic conditions (e.g. colonic carcinoma, which requires urteric resection).
   • Mainly indicated for upper and midureteral involvement. The procedure of choice for lower ureteric involvement is reimplantation into the bladder.

Rupture Of The Urinary Bladder

Causes of Urinary Bladder Rupture:

1. Surgical (iatrogenic): The bladder can be injured mostly during pelvic surgery (e.g. excision of the rectum) or during gynaecological procedures.
2. Trauma: Blunt injury to the abdomen due to road traffic accidents.
   • Kick or blow on the abdomen with a full bladder
   • Penetrating injury (extremely rare).

Types of Rupture and Clinical Features:

1. Intraperitoneal Rupture:

When there is surgical trauma or trauma to a distended bladder, the rupture will be intraperitoneal.

Clinical features

• Sudden, severe suprapubic pain, hypotension/ syncope, and shock.
• Lower abdominal guarding and rigidity occur after a few hours of injury.
• Distension
• Even though the patient has not passed urine for a few hours, there is no desire to micturate.
• Shifting dullness may be elicitable.

2. Extraperitoneal Rupture:

• Trauma—penetrating or blunt injury with fracture of pubis gives rise to this type of injury.
• Difficult to distinguish clinically from an injury to the membranous urethra.

Investigations:

1. Plain X-ray abdomen: Lower abdomen shows a ground glass appearance.
2. IVP: Extravasation of dye into the peritoneal cavity or extraperitoneally.
3. CT cystogram is the investigation of choice.

Treatment:

1. Intraperitoneal rupture: Laparotomy and repair of the bladder in two layers with vicryl. Drain the suprapubic space with a tube drain. An indwelling urethral catheter has to be placed for 10 days to 2 weeks to keep the bladder decompressed.
2. Extraperitoneal rupture: Extraperitoneal expose the bladder with a suprapubic midline incision and repair the bladder. Drainage, as mentioned above, should be carried out.

Surgical Anatomy Of The Urethra

• The male urethra is divided into an anterior urethra (bulbopenile) and a posterior urethra (prostatomembranous urethra).
• The male urethra functions as a conduit for urine and semen. The anterior urethra is covered with erectile tissue of the corpus cavernosum and penetrates the urogenital diaphragm to enter the pelvic cavity as the prostatomembranous urethra.
• Since its margins are attached to the perineal membrane, it is vulnerable to tear at this point in pelvic bone fracture.
• The length of the male urethra is about 18–20 cm.
• The entire urethra is supplied by the internal pudendal artery.
• Veins drain into Santorini’s plexus around the bladder neck and prostate.
• The female urethra is short (4 cm), drains only urine, and is not vulnerable to injuries.
• The narrowest part of the male urethra is the external meatus.
• The prostatic urethra has two sphincters at each end.
• The internal sphincter at the bladder neck is composed of smooth muscle fibres, and the external sphincter is a rhabdosphincter about 2 cm long that surrounds the membranous urethra.
• Normally, urinary continence is maintained by the external sphincter. When the external sphincter is damaged (e.g. trauma, surgery) the internal sphincter maintains continence but to a lesser degree.
• Continence is not affected by ablation of the internal sphincter (e.g. post-transurethral resection of the prostate; TURP), but it results in retrograde ejaculation (i.e., the semen goes back into the bladder instead of exiting through the urethra).

Rupture Urethra

Types:

1. Rupture Bulbar Urethra:

• The most common urethral injury.
• The urethra angulates in the perineum, where it gets injured.
• Superficial extravasation of urine.

Clinical triad

1. Perineal haematoma
2. Urethral haemorrhage: Blood at the urethral meatus
3. Distended bladder: Diagnosed by percussion over the suprapubic region which gives a dull note.

Treatment:

• Advise the patient to try avoiding the passage of urine.
• Urinary antibiotics
• Shift to the operation theatre, and with aseptic precautions, gently pass a catheter. If it enters the bladder, it is kept in place for 2 weeks, and the perineal haematoma is drained.
• If unable to pass the catheter, emergency suprapubic cystostomy/catheterization is done to drain the urine, and repair of the urethra is done later.

2. Rupture Membranous Urethra:

• Associated (70%) with fracture of the pelvis.
• Occurs in major road traffic accidents.
• There may be disruption of the pelvic bones and fracture symphysis pubis with avulsion of the puboprostatic ligament, leading to floating prostate.
• Deep extravasation of urine.

Types of rupture membranous urethra:

1. Complete transection results in floating bladder. In this condition, the urethra is completely transected at the apex of the prostate. As the puboprostatic ligament is avulsed, the prostate falls back and migrates upwards. On rectal examination, the prostate is felt as though it is floating—floating prostate (Vermooten’s sign).

2. Incomplete transaction

3. Associated with injury to the bladder: Extraperitoneal rupture of the bladder is seen here. (Intraperitoneal rupture of bladder occurs in a distended bladder.)

Clinical Features

• History of injury
• Features of shock due to significant blood loss (around 1–2 litres)
• Haematuria
• In cases of extraperitoneal rupture of the bladder, it will not be palpable due to extravasation of urine into the perineum.
• Suprapubic tenderness and dullness

Rectal examination: Floating prostate can be felt and is tender.

Investigations

1. X-ray pelvic bones may show a fracture or separation of the pubic symphysis.
2. Ascending urethrography (ASU) to confirm the rupture.
3. Once the stricture develops, voiding cystourethrogram (VCUG) is done to know the exact location and length of the stricture.

Treatment:

• Urgent blood transfusion to treat shock.
• Suprapubic cystostomy is done, and the degree of damage is assessed.
• A bougie/sound is passed from above and another similar sound is passed through the external meatus (penis). When the two meet, a click is appreciated.
• With both sounds in contact, the sound from the bladder is slowly withdrawn. The lower one is advanced at this stage, and a second sound appears in the bladder. A red rubber catheter is tied to it, and the sound is withdrawn through the external meatus.
• To this red rubber catheter which is seen outside, a Foley catheter is tied and is drawn into the bladder and kept in place for 15 days (rail roading technique; progressive perineal urethroplasty).
• Associated injuries, such as rupture bladder, are treated by suturing.
• Antibiotics are given

Complications of Rupture Urethra:

The most dangerous complication is the stricture urethra.

Stricture Urethra

Causes:

1. Congenital—very rare

2. Post-inflammatory

• Post-gonococcal urethritis
  • Within 48 hours of exposure to the venereal disease gonorrhoea, periurethral gland involvement occurs. These are concentrated more in the bulbar urethra, so strictures are more common at this site.
  • It causes periurethral fibrosis, resulting in multiple dense strictures within 1 year of infection but may not cause difficulty in micturition for 10–15 years.

3. Post-instrumentation:

• Catheterisation
• Dilatation
• Transurethral procedures

4. Postoperative:

• Prostatectomy
• Repair of rupture urethra

5. Schistosomiasis

Clinical Features

Previous history of exposure to gonorrhoea, history of instrumentation, or history of trauma to the urethra is usually present.

• Common in young age (20–40 years).
• History of straining while passing urine.
• Suprapubic pain and swelling due to distended bladder.
• Stricture urethra may be felt in the perineum as a button hole.

It should be remembered that gonococcal urethritis is not common nowadays because of effective treatment for the disease.

Treatment

Usually cut at 12 O’clock position.

1. Visual internal urethrotomy (VIU) by using a urethrotome.

2. Open method is indicated in long strictures that do not respond to less invasive procedures. They are grouped under urethroplasty.

1. Excision and end-to-end urethroplasty
2. Non-transecting anastomotic urethroplasty
3. Substitution urethroplasty—buccal mucosa, skin
4. Two-step urethroplasty

3. Regular dilatation with Lister’s dilators.

Complications:

1. Acute retention of urine.
2. Secondary stones due to proximal stasis of urine.
3. Recurrent periurethral abscesses (multiple) which rupture and open externally in the perineal skin. When such a patient is asked to pass urine, urine can be seen coming out of multiple holes in the perineum (Watercan perineum).
4. Recurrent epididymo-orchitis.

Hypospadias

In this condition, some portion of the distal urethra is not developed, resulting in the external meatus being situated in the under surface of the penis. Usually, this is associated with chordee and hooded prepuce.

Types:

1. Glandular variety: The external meatus is situated a few mm away from the normal site within the glans.

2. Coronal variety:

• It occurs due to failure of the development of the urethra that runs in the glans penis.
• As a result of this, the urethra opens at the corona glandis—junction of the glans and shaft of the penis.

• Both these varieties do not give major functional problems. It can be left alone without treatment.

3. Penile hypospadias: The external opening is situated somewhere in the under surface of the penis.

4. Penoscrotal/perineal hypospadias:

• In this condition, the entire urethra is not developed.
• The penis is rudimentary.
• The urethral opening is seen between two halves of the scrotum and is often split.
• Cases may be associated with undescended testes.
• In such cases, it is difficult to differentiate the sex of the child.

Clinical Features

• Occurs in 1:350 males.
• Micturition: Stream is good, but it wets the clothes in the third and fourth varieties.
• Chordee: Many cases are associated with bending of the penis.
• Sexual intercourse will be difficult.
• Hooded prepuce.

In severe hypospadias, the possibility of sexual differentiation disorders is settled by karyotyping.

Treatment

1. One-stage urethroplasty:

• Chordee correction: Always confirm by inducing artificial erection
• Urethral tube formation by tubularising the urethra
• Inner prepuceal island tube urethroplasty.

2. Two-stage urethroplasty:

• When the child is 6–12 months old, chordee is corrected by straightening the penis (orthoplasty).
• When the child is 5–6 years old, reconstruction of the urethra is done using locally available skin either from the prepuce or the penile shaft (urethroplasty). Hence, circumcision should not be done in hypospadias.

Differential Diagnosis Of Urinary Retention

Causes of Urinary Retention:

1. Acute Urinary Retention:

1. In males:
   • Benign prostatic hypertrophy (BPH): In elderly patients > 50 years of age.
   • Stricture urethra: In young patients.
   • Postoperative retention of urine: Operations like haemorrhoidectomy, fistulectomy, etc., produce reflex spasms of the internal sphincter, which precipitates urinary retention. The management of such cases.
2. In females
   • Hysteria
   • Retroverted gravid uterus
   • Urethral stenosis
3. In children: Meatal stenosis due to meatal ulcer with a scab (due to scratching by the child).
4. In general
   • Spinal anaesthesia
   • Spinal injuries
   • Blood clot in the bladder following prostatectomy
   • Bladder stone in school-going children: Pain referred to the tip of the penis
   • Acute urethritis and acute prostatitis due to bacterial infection
   • Faecal impaction in the rectum
   • Contracture of the bladder neck
   • Urethral calculus
   • Drugs: Atropine, carbachol, bethanechol.

2. Chronic Urinary Retention:

1. Benign prostatic hypertrophy
2. Bladder neck contracture
3. Stricture urethra

Residual urine:

It is significant if > 40% of voided volume is present.

Differential diagnoses include BPH, stricture urethra, and underactive bladder.

Posterior Urethral Valve (PUV)

• They are congenital, symmetrical valves in the posterior urethra.
• It is a common cause of vesicoureteric reflux and hydronephrosis in infants.
• The bladder wall is thickened due to obstruction and hypertrophy. The urinary bladder is palpable, hard, and felt in the suprapubic region—cricket ball bladder.
• Due to stasis, recurrent UTI commonly occurs.
• It is also a common cause of renal failure in infancy and childhood.

Investigations

• Ultrasound: Bilateral hydronephrosis, thickened bladder, etc.
• Micturating cystourethrography (MCU): Dilated proximal urethra is highly suggestive of a posterior urethral valve. It is a diagnostic investigation.

Treatment:

• Cystoscopic posterior urethral valve fulguration.
• In very ill patients, vesicostomy is done initially to improve renal function and stabilise the patient. Fulguration is done after 1–2 weeks.
• These patients should be monitored for renal failure by serial creatinine measurements.

Vesicoureteric Reflux(VUR)

VUR is the retrograde flow of urine from the bladder to the kidneys.

Normally, urine flows from the kidneys into the bladder, and backward flow is prevented by complex anatomy at the vesicoureteric junction, most importantly a good length of the submucosal tunnel of the ureter. The inadequate submucosal tunnel leads to VUR. VUR can be of a mild to severe grade (graded I— mild to V—severe).

Clinical Features

• The child may be diagnosed with hydronephrosis antenatally, depending on the severity of reflux.
• Recurrent UTI: This is due to the increased amount of residual urine. When the child voids, some urine refluxes back into the kidneys, which comes back into the bladder after voiding ceases. This leads to high post-void residue (PVR) and causes recurrent infections.
• Pyelonephritis and scarring: Reflux of infected urine causes pyelonephritis. It can be acute or chronic Recurrent episodes can lead to kidney scarring and decreased function, proteinuria, and hypertension. Severe scarring bilaterally may lead to chronic renal failure (CRF) and end-stage renal disease (ESRD).

Investigations:

• Urine analysis for proteinuria and infection.
• Complete blood picture: Anaemia in CRF and leukocytosis in acute pyelonephritis.
• Renal function tests: Increased urea and creatinine in renal failure.
• USG: Renal size, parenchyma and hydroureteronephrosis with PVR can be assessed.
• MCU or VCUG: Investigation of choice for diagnosis.
• Procedure: Bladder is filled with contrast after catheterisation, and X-rays are taken during filling and with full bladder to look for reflux.
• After a full bladder, the catheter is removed, the patient is asked to void, and X-rays are taken in the voiding phase.
• DMSA scan: For the extent of renal scarring and function. Helps in choosing the management strategy (medical vs surgical).

Treatment:

1. Conservative management: Low-grade reflux (grades I–III) can be managed conservatively. The aims of conservative therapy include:

• Prophylactic/suppressive antibiotics.

• Regular or timed voiding and double voiding to keep PVR as low as possible.
• To avoid constipation—reduces the incidence of UTI.
• With these measures, most low-grade refluxes resolve spontaneously.
• Higher-grade refluxes require endoscopic or surgical management.

2. Endoscopic management: Injection of a bulking agent to provide support to the VUJ helps in a few cases.

3. Surgical management: Ureteric reimplantation is done for high-grade reflux. The principle of surgery is to lengthen the submucosal tunnel. If one kidney is poorly functioning, nephrectomy can be done. In some cases, bilaterally scarred, nonfunctioning kidneys may lead to ESRThese patients require renal transplantation.

Miscellaneous

Urinary Bladder And Urethra Multiple Choice Questions

Question 1. The following types of malignant tumours can occur in the urinary bladder except:

1. Transitional carcinoma
2. Adenocarcinoma
3. Squamous cell carcinoma
4. Leiomyosarcoma

Answer: 4. Leiomyosarcoma

Question 2. The following are true regarding the internal sphincter of the urinary bladder:

1. It is a smooth muscle
2. It is innervated by adrenergic fibres
3. It prevents retrograde ejaculation
4. It is supplied by the pudendal nerve

Answer: 4. It is supplied by the pudendal nerve

Question 3. Cystine calculi in the urinary bladder are radiopaque because of:

1. High calcium content
2. High sulphur content
3. High triple phosphate content
4. High oxalate content

Answer: 2. High sulphur content

Question 4. The following are clinical features of urinary bladder stones except:

1. Pain referred to the testis
2. Pain aggravated by jumping
3. Strangury
4. Haematuria

Answer: 1. Pain referred to the testis

Question 5. Which of the following parasitic infestations is a strong risk factor for carcinoma urinary bladder?

1. Bilharziasis
2. Ascariasis
3. Leishmaniasis
4. Clonorchis sinensis

Answer: 1. Bilharziasis

Question 6. The following are true for carcinoma urinary bladder except:

1. Aniline dye workers are at high risk
2. Transitional cell carcinomas are more common
3. It presents with strangury
4. Adenocarcinoma is due to bilharziasis

Answer: 4. Adenocarcinoma is due to bilharziasis

Question 7. The following are true in ectopia vesicae except:

1. Penis is normal
2. The posterior wall of the urinary bladder is seen
3. The pubic symphysis is widely separated
4. Adenocarcinoma of the urinary bladder occurs very early

Answer: 1. Penis is normal

Question 8. The most common organism causing acute cystitis is:

1. E.coli
2. Klebsiella
3. Proteus
4. Pseudomonas

Answer: 1. E.coli

Question 9. The following are causes for vesicovaginal fistula except:

1. Protracted labour
2. Anterior colporrhaphy
3. Radiation
4. Crohn’s disease

Answer: 4. Crohn’s disease

Question 10. The most worrying complication following ureterosigmoidostomy is:

1. Acidosis
2. Adenocarcinoma
3. Alkalosis
4. Recurrent infection and septicaemia

Answer: 2. Adenocarcinoma

Question 11. Which of the following is not a feature of intraperitoneal rupture of the urinary bladder?

1. Shock
2. Urgent and frequent desire to pass urine
3. Suprapubic pain
4. Hypotension

Answer: 2. Urgent and frequent desire to pass urine

Question 12. Which is the narrowest portion of the male urethra?

1. Penile urethra
2. External meatus
3. Perineal urethra
4. Bulbar urethra

Answer: 2. External meatus

Question 13. Which of the following is not part of the triad of bulbar urethral rupture?

1. Perineal haematoma
2. Blood at the urethral meatus
3. Distended bladder
4. Floating prostate

Answer: 4. Floating prostate

Question 14. What is the first advice given to patients with bulbar urethral rupture?

1. Blood transfusion
2. Intravenous antibiotics
3. Avoid passing urine
4. Immediate catheterisation

Answer: 3. Avoid passing urine

Question 15. Floating prostate—Vermooten’s sign is classical of:

1. Rupture bulbar urethra
2. Rupture penile urethra
3. Rupture intraperitoneal urinary bladder
4. Rupture membranous urethra

Answer: 4. upture membranous urethra

Question 16. Which of the following is true for posterior urethral valves?

1. They are acquired
2. Bladder is thin-walled and more prone for rupture
3. Renal failure is uncommon
4. They are symmetrical

Answer: 4. They are symmetrical