Urological Conditions

Bladder Cancer

The bladder is an organ located in the pelvic cavity that stores and discharges urine. Urine is produced by the kidneys, carried to the bladder by the ureters, and discharged from the bladder through the urethra. Bladder cancer accounts for approximately 90% of cancers of the urinary tract (renal pelvis, ureters, bladder, urethra).

Bladder cancer usually originates in the bladder lining, which consists of a mucous layer of surface cells that expand and deflate (transitional epithelial cells), smooth muscle, and a fibrous layer. Tumors are categorized as low-stage (superficial) or high-stage (muscle invasive).

In industrialized countries (e.g., United States, Canada, France), more than 90% of cases originate in the transitional epithelial cells (called transitional cell carcinoma; TCC). In developing countries, 75% of cases are squamous cell carcinomas caused by Schistosoma haematobium (parasitic organism) infection. Rare types of bladder cancer include small cell carcinoma, carcinosarcoma, primary lymphoma, and sarcoma.

Bladder Control Problems

In people with an overactive bladder (OAB), the layered, smooth muscle that surrounds the bladder (detrusor muscle) contracts spastically, sometimes without a known cause, which results in sustained, high bladder pressure and the urgent need to urinate (called urgency). Normally, the detrusor muscle contracts and relaxes in response to the volume of urine in the bladder and the initiation of urination.

People with OAB often experience urgency at inconvenient and unpredictable times and sometimes lose control before reaching a toilet. Thus, overactive bladder interferes with work, daily routine, intimacy and sexual function; causes embarrassment; and can diminish self-esteem and quality of life.

Urination (micturition) involves processes within the urinary tract and the brain. The slight need to urinate is sensed when urine volume reaches about one-half of the bladder's capacity. The brain suppresses this need until a person initiates urination.

Once urination has been initiated, the nervous system signals the detrusor muscle to contract into a funnel shape and expel urine. Pressure in the bladder increases and the detrusor muscle remains contracted until the bladder empties. Once empty, pressure falls and the bladder relaxes and resumes its normal shape.

Benign Prostatic Hyperplasia (BPH)

A condition that affects the prostate gland in men. The prostate is a gland found between the bladder (where urine is stored) and the urethra (the tube urine passes through). As men age, the prostate gland slowly grows bigger (or enlarges). As the prostate gets bigger, it may press on the urethra and cause the flow of urine to be slower and less forceful. "Benign" means the enlargement isn't caused by cancer or infection. "Hyperplasia" means enlargement.

Most symptoms of BPH start gradually. One symptom is the need to get up more often at night to urinate. Another symptom is the need to empty the bladder often during the day. Other symptoms include difficulty in starting the urine flow and dribbling after urination ends. The size and strength of the urine stream may decrease.

These symptoms can be caused by other things besides BPH. They may be signs of more serious diseases, such as a bladder infection or bladder cancer. Tell your doctor if you have any of these symptoms, so he or she can decide which tests to use to find the possible cause.

Erectile Disease

Impotence or erectile dysfunction takes many forms and affects 10-15 percent of all males and can be emotionally and psychologically disabling for men and their partners. In 80% of erectile dysfunction cases, physical factors such as drugs, blood flow abnormalities, nerve impulse abnormalities or hormonal abnormalities are the major causes. Psychological factors account for the remaining cases and may be attributed to stress, performance anxiety and misinformation about sexuality.

Impotence or erectile dysfunction, is the inability to achieve an erection, and/or dissatisfaction with the size, rigidity, and/or duration of erections. Erectile dysfunction affects millions of men.

Although in the past it was commonly believed to be due to psychological problems, it is now known that 80 to 90 percent of impotence is caused by physical problems, usually related to the blood supply of the penis.

Hematuria

What is Hematuria?

Hematuria is a medical term for blood in the urine. This may be visible, known as gross hematuria, or it may be invisible to the naked eye, known as microscopic hematuria.

What causes hematuria?

Hematuria can be of many causes. These include tumors, stones, infection, obstruction, blockage or trauma. Also, a patient may have blood in the urine related to the internal workings of the kidney and possibly from anticoagulation therapy for heart disease, strokes, etc.

What are some of the symptoms of hematuria?

Symptoms depend on the cause and may vary. Commonly, the only sign the patient has is the actual visual observation of blood, or the microscopic hematuria may be picked up on a routine physical examination by the patient's physician doing routine lab work. The other end of the spectrum may include significant pain and problems urinating.

How is hematuria generally treated?

Obviously, the treatment (if needed) depends on the cause. Tumors or stones may need to be removed. Obstruction or blockage may need to be corrected. Infection may warrant antibiotics. Trauma may require any number of interventions depending on the cause, location and severity. In a patient who is on anticoagulation therapy such as Coumadin, the dosage of those medications may need to be adjusted.

What are some of the methods of prevention of hematuria?

Prevention of hematuria depends on the cause. Trauma or tumors usually are difficult to predict and thus prevent. However, infections or stones many times can be prevented or curtailed.

How serious is hematuria? Do all people with hematuria need to be treated?

Not all people with hematuria need to be treated. However, treatment depends on the cause, and the cause can only be found after a thorough investigation by a urologist. A urologist is a doctor who specializes in urinary tract problems.

Male Infertility

Infertility is the inability to conceive after at least one year of unprotected intercourse. Since most people are able to conceive within this time, physicians recommend that couples unable to do so be assessed for fertility problems. In men, hormone disorders, illness, reproductive anatomy trauma and obstruction, and sexual dysfunction can temporarily or permanently affect sperm and prevent conception. Some disorders become more difficult to treat the longer they persist without treatment.

Sperm development (spermatogenesis) takes place in the ducts (seminiferous tubules) of the testes. Cell division produces mature sperm cells (spermatozoa) that contain one-half of a man's genetic code. Each spermatogenesis cycle consists of six stages and takes about 16 days to complete. Approximately five cycles, or 2 ? months, are needed to produce one mature sperm. Energy-generating organelles (mitochondria) inside each sperm power its tail (flagellum) so that it can swim to the female egg once inside the vagina. Sperm development is ultimately controlled by the endocrine (hormonal) system that comprises the hypothalamic-pituitary-gonadal axis.

Because sperm development takes over 2 months, illness that was present during the first cycle may affect mature sperm, regardless of a man's health at the time of examination.

According to the National Institutes of Health, male infertility is involved in approximately 40% of the 2.6 million infertile married couples in the United States. One-half of these men experience irreversible infertility and cannot father children, and a small number of these cases are caused by a treatable medical condition.

Microwave Therapy

A type of treatment in which body tissue is exposed to high temperatures to damage and kill cancer cells or to make cancer cells more sensitive to the effects of radiation and certain anticancer drugs. TransUrethral Microwave Thermotherapy (TUMT) and TransUrethral Needle Ablation (TUNA) are used for benign prostatic hyperplasia, but not prostate cancer.

Prostate Cancer

Adenocarcinoma of the prostate is the clinical term for a cancerous tumor on the prostate gland. As prostate cancer grows, it may spread to the interior of the gland, to tissues near the prostate, to sac-like structures attached to the prostate (seminal vesicles), and to distant parts of the body (e.g., bones, liver, lungs). Prostate cancer confined to the gland often is treated successfully.

The prostate gland is located in the pelvis, below the bladder, above the urethral sphincter and the penis, and in front of the rectum in men. It is made up of glandular tissue and muscle fibers that surround a portion of the urethra. The gland is covered by a membrane (called the prostate capsule) that produces prostate-specific antigen.

According to the American Cancer Society (ACS), prostate cancer is the most common type of cancer in men in the United States, other than skin cancer. The ACS estimates that about 230,900 new cases will be diagnosed in 2004 and about 29,900 men will die of the disease. Prostate cancer is the second leading cause of cancer death in men, exceeded only by lung cancer.

Prostate cancer occurs in 1 out of 6 men. Reports of diagnosed cases have risen rapidly in recent years and mortality rates are declining, which may be due to increased screening.

African American men have the highest incidence of prostate cancer, and Asian and Native American men have the lowest incidence. Rates for Asian and African men increase sharply when they emigrate to the United States, suggesting an environmental connection (e.g., high-fat diet, smoking).

PSA

What is PSA?

Prostate specific antigen is a protein that is made specifically by the prostate gland. It is not made by any other organ and if you do not have any prostate tissue or prostate cancer, then your PSA will be zero.

What is the normal "range" for PSA?

The normal range for a PSA for a normal male is less than 4 ng/ml. We do allow the PSA to float upward above the age of 75 though again it is in a certain range to be determined by the urologist.

What are the causes for an increased PSA?

The PSA is a protein made by the prostate gland and prostate tissue and may be elevated due to certain disease processes of the prostate gland. These include inflammation, infection, enlargement and cancer. It is your urologist's job to try to determine which one of these causes produce the elevated PSA. We especially are on the lookout for an early asymptomatic cancer and this should be determined with an ultrasound and biopsy which is done in the office.

How is it treated?

An elevated PSA, per se, does not require treatment. The elevated PSA is an indication of disease or a problem with the prostate, sometimes needing treatment and sometimes not. The main reason the PSA is done is to evaluate which patients need to be further looked at and which ones fall into the "normal range." The importance of PSA is to do a screening of those which we want to take a "further look at."

Does an elevated PSA always mean cancer?

No. As we have previously discussed in the questions above, the PSA can be increased with benign conditions and is not always associated with cancer.

How often should I get a PSA?

The recommendations are that a PSA should be drawn and evaluated once a year for patients from 50 years of age to 75 years of age along with a digital rectal exam. If there is a close family member with a history of prostate cancer this may be reduced to the age of 40 or 45. Generally, in African-Americans we start drawing the PSA 5 years sooner at the age of 45.

Urinary Stone Disease

Most urinary stones pass through the collecting system in an uneventful fashion. When a ureteral stone becomes obstructed it can result in severe pain with associated nausea and vomiting. Stones less than 5 mm in size have a 50% chance of spontaneous passage within a six-week period of time. If a patient has uncontrollable pain, persistent vomiting or a fever intervention is indicated. The imaging modality of choice is the non-contrast CT scan. All stone types except protease inhibitors (used in immuno-compromised patients) will be visualized. It eliminates the need for intravenous contrast, a skilled technician, and has the added benefit of imaging the entire abdomen and pelvis.

Urinary Tract Infection (Male & Female)

Urinary tract infection (UTI) is a common infection that usually occurs when bacteria enter the opening of the urethra and multiply in the urinary tract. The urinary tract includes the kidneys, the tubes that carry urine from the kidneys to the bladder (ureters), bladder, and the tube that carries urine from the bladder (urethra). The special connection of the ureters at the bladder help prevent urine from backing up into the kidneys, and the flow of urine through the urethra helps to eliminate bacteria. Men, women, and children develop UTIs.

Urinary tract infections usually develop first in the lower urinary tract (urethra, bladder) and, if not treated, progress to the upper urinary tract (ureters, kidneys). Bladder infection (cystitis) is by far the most common UTI. Infection of the urethra is called urethritis. Kidney infection (pyelonephritis) requires urgent treatment and can lead to reduced kidney function and possibly even death in untreated, severe cases.

Approximately 8 to 10 million people in the United States develop a UTI each year. Women develop the condition much more often than men, for reasons that are not fully known, although the much shorter female urethra is suspected. The condition is rare in boys and young men.

Twenty percent of women in the United States develop a UTI and 20% of those have a recurrence. Urinary tract infections in children are more common in those under the age of 2.

Urodynamics

Urodynamics is the investigation of the function of the lower urinary tract - the bladder and urethra - using physical measurements such as urine pressure and flow rate as well as clinical assessment.

The assessment begins with a medical history and examination, which may for example reveal abnormalities within the lower abdomen or pelvis that are contributing to the lower urinary tract symptoms.

The patient is then given a urination (voiding) diary to be kept for three days, to document their fluid intake and output, including episodes of incontinence. This provides information about bladder capacity, the frequency of passage of urine and episodes of incontinence and getting up at night to urinate. The diary can also outline other problems such as excessive fluid intake.

Vasectomy

Vasectomy is a minor surgical procedure to cut and close off the tubes (vas deferens) that deliver sperm from the testes; it is usually performed as a means of contraception. The procedure typically takes about 30 minutes and usually causes few complications and no change in sexual function. About 500,000 vasectomies are performed annually in the United States. A vasectomy is less invasive than a tubal ligation (i.e., the procedure used to prevent a woman's eggs from reaching the uterus) and more easily reversed. An increasing number of couples choose it as a means of permanent birth control.

To understand a vasectomy, it is helpful to understand the male reproductive system and how it functions. The testicles, or testes, are the sperm- and testosterone-producing organs. They are located in a sac at the base of the penis called the scrotum. Each testicle is connected to a small, coiled tube called the epididymis, where sperm are stored for as long as 6 weeks while they mature. The epididymes are connected to the prostate gland by a pair of tubes called the vas deferens. The vas deferens are part of a larger bundle of tissue, blood vessels, nerves, and lymphatic channels called the spermatic cord. During ejaculation, seminal fluid produced by the prostate gland mixes with sperm from the testes to form semen, which is ejaculated from the penis.

Vasectomy Reversal

Reversals are generally performed in an outpatient area of a hospital or in an ambulatory surgery center. The operation may be performed with local, epidural ("saddle block"), spinal or general anesthesia. The choice will depend on the preference of the surgeon, patient and anesthesiologist.

Once the patient is anesthetized, the urologist will make small incisions (cuts) on each side of the scrotum and first remove the scarred ends of the vas at the point of blockage created by the vasectomy. The urologist will then extract a fluid sample from the end closest to the testicle to examine the fluid to see if it contains sperm.

The presence of sperm in the fluid is an indication that there is no obstruction between the testicle and the location in the tube from which the fluid was obtained, and particularly that there is no blockage in the tube in the epididymis. When sperm are present in the fluid, the passage can be reestablished by reconnecting the ends of the vas. The medical term for reconnecting the ends of the vas is vasovasostomy. This may be accomplished with one of several methods.

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