Anatomy of the Genitourinary System in the Kingdom of Bahrain

1. Kingdom of BahrainArabian Gulf UniversityCollege of Medicine and Medical Sciences Surgery Subspecialty The Genitourinary System Ali Jassim Alhashli

2. Anatomy • Penis: • It is composed of 3 cylindrical bodies: • Two corpora cavernosa: representing the erectile tissue of the penis; covered by tunica albuginea. • One corpus spongiosum: surrounding the urethra. • Blood supply: • Arterial supply: internal pudendal artery. • Venous drainage: superficial and deep dorsal veins of the penis draining to pudendal vein. • Lymphatic drainage: superficial and deep inguinal lymph nodes. • Scrotum: • It consists of: • Smooth muscle. • Darto’s fascia: it is a continuation of Scarpa’s fascia of the abdominal wall. • Arterial blood supply: • Femoral artery. • Internal pudendal artery. • Lymphatic drainage: • Femoral lymph nodes. • Inguinal lymph nodes.

3. Anatomy

4. Testes: • They are covered by tunica albuginea (similar to corpora cavernosa) except on their postero-lateral aspect (site of attachment of epididymis). This entire unit us wrapped by tunica vaginalis which attaches both testicle to the scrotum via the gubernaculum. • Bell-clapper deformity: it is absence of gubernaculum which attaches testes to scrotum thus increasing the risk of testicular torsion. • Vestigial (non-functional) structures of testes: • Appendix testis: located on posterior aspect of the testicle; Mullerian duct origin. • Appendix epididymis: located on the epididymis; Wolffian duct origin. Notice that torsion of these structures can cause pain mimicking testicular torsion, but in this case patient can be managed with NSAIDs. • Blood supply: • Arterial supply: testicular artery, cremasteric artery and artery of Vas. • Venous drainage: Pampiniform plexus of veins which is draining to testicular vein. • Lymphatic drainage: mainly to para-aortic lymph nodes. • Epididymis: • It is a tubular structure which originates from Wolffian duct. • It is composed of: head, body and tail (vas deferens is continuation of the tail of epididymis). • 5 m in length compressed in an area of 5 cm ! • Function: site of sperm motility and maturation. • Vas deferens: • It originates from Wolffian duct. • It exits scrotum laterally → travels through inguinal canal → crosses medially behind bladder and over ureters to form ampulla of vas deferens → joins seminal vesicles to form ejaculatory ducts draining in prostatic urethra. • Prostate: • It originates from urogenital sinus and matures via dihydrotestosterone. • Its posterior surface can be palpated through digital rectal examination. Anatomy

5. Anatomy

6. Anatomy

7. Kidney: • It is a retroperitoneal organ which lies obliquely on: psoas muscle and quadratuslumborus. • Renal hilum consists of (anterior to posterior): vein, artery, ureter. • It is surrounded by perirenal fat. • Both kidneys and adrenal glands are contained within Gerota’s fascia. • Adrenal gland is located superior-medially to the kidney. • Ureters: • Travel along psoas muscle → cross the pelvic at the bifurcation internal and external iliac arteries → travel medially toward the bladder (inserting posteriorly). • Narrowest points at which a stone can cause obstruction: • Ureteropelvic junction. • Pelvic brim. • Ureterovesical junction. • Bladder/urethra: • Bladder consists of: • Detrusor muscle. • Transitional epithelium. • Physiology: • Detrusor muscle and internal urethral sphincter are smooth muscles and under the control of sympathetic/parasympathetic systems. • External urethral sphincter is a striated muscle and under voluntary control. Anatomy

8. Anatomy

9. Hematuria • Definition: it is the presence of blood in the urine which can be gross or microscopic (≥ 3 RBCs/hpf). • Notice that the presence of RBC cast indicates glomerular bleeding. • False positive on dipstick occurs when myoglobin is present. • Gross hematuria with negative dipstick: dye in beets and berries, some food colorings and rifampin. • Causes: • Stones. • Bladder cancer. • Trauma. • Acute UTI/cystitis/urethritis/prostatitis • Glomerulonephritis. • Renal Cell Carcinoma (RCC). • Sickle cell disease.

10. Priapism: • Definition: it is PAINFULL, persistent erection of the penis (< 4 hours) not triggered by sexual stimulation. • Types: • Low flow: • Characteristics: common, PAINFULL, ischemic, pH = 7.2 and entirely erect. • Causes: sickle cell disease, sildenafil, intracoporealalprostadil injections and cocaine. • Treatment: intracorporealphenylephrine injections. • High flow: • Characteristics: less common, PAINLESS, not ischemic, pH = 7.4 • Cause: AV fistula secondary to trauma. • Treatment: embolization of AV fistula. • Acute scortum: • Differential diagnoses: testicular torsion, torsion of testicular appendages, trauma, hydrocele, varicocele and epididymo-orchitis. • Physical examination, check for the following: • Swelling of scrotum. • Position of testicles. • Presence of any skin changes (erythema, warmth, discoloration). • Cremasteric reflex. • Transillumination: differentiates hydrocele from solid testicular mass. • Prehn’s sign: relieve of pain by elevation of testicle (epididymitis). • Presence of urethral discharge. Priapism and Acute Scrotum

11. Testicular Torsion • Definition: twisting/rotation of testis around the spermatic cord which results in compromised blood flow and ischemia that can be reversed if there is surgical intervention within 6 hours. • Epidemiology: occurs in 1st year of life and at puberty. • Causes: • There is a high risk with undescended testis. • Bell-clapper deformity. • Signs and symptoms: • Acute scrotal pain which may radiate to the groin/lower abdomen. • Scrotum is tender, swollen and empty (testicle is elevated and might be in a horizontal lie). • Loss of cremasteric reflex. • Diagnosis: • Duplex ultrasound: showing presence of absence of blood flow to the suspected testis. • Treatment: • Testis is viable: bilateral orchiopexy (fixing testicle to the scrotum). • Necrotic testis: orechiectomy with orchiopexy for the other testicle.

12. Testicular Torsion

13. Epidemiology: • Testicular cancer has a bimodal distribution (early childhood or 20-35 years of age). • More common among whites. • Risk factors: • Undescended testicle (especially if it is intrabdominal). This increases the risk for testicular cancer in both testicles. Even if the undescended testicle is brought down to the scrotum there is still a risk for cancer! • Signs and symptoms: • PAINLESS, firm mass which does not transilluminate. • Weight loss. • Patient might have back pain or abdominal pain if there is lymphadenopathy. • Dyspnea (if there is pulmonary metstasis). • Gynecomastia (if the tumor secretes hormones). • Diagnosis: • Physical examination. • Ultrasound. • Staging: CXR and abdominopelvic CT-scan. • Tumors markers: AFP, LDH and hCG. • Classifications: • Germinal (95%): • Seminoma: only 10% secrete hCG. • Non-seminoma: embryonal cell carcinoma, teratoma or choriocarcinoma (100% ↑ in β-hCG). • Combination tumors. • Stroma: • Leydig cell. • Sertoli cell. • Gonadoblastoma (germinal + stromal). Testicular Cancer

14. Testicular Cancer

15. Testicular Cancer • Staging: • Stage-I: tumor within testis; tumor markers normalize after orchiectomy. • Stage-II: retroperitoneal lymphadenopathy and subdiaphragmatic disease; tumor markers will not normalize after orchiectomy. • Stage-III: distant metastasis or visceral involvement. • Treatment: • Surgical procedure: high radical inguinal orchiectomy (testicle and full spermatic cord are being removed through an incision in inguinal region). NOTICE THAT TRANS-SCROTAL BIOPSY OR ORCHIECTOMY ARE CONTRAINDICATED TO PREVENT THE SPREAD OR RECURRENCE OF CANCER. • Prognosis of seminomas is excellent due to their high sensitivity to radiotherapy. • The most commonly used chemotheraptuic regimen is: etoposide, bleomycin and cisplatin.

16. Epidemiology: • More common among males. • Higher risk if there is a family history. • Recurrence after personal past history of stone formation: • 36% within 1 year. • 50% within years. • Types of stones: • Calcium oxalate (most common-75%). • Magnesium-ammonium-phosphate (15%): seen in UTI with urease –splitting bacteria (Proteus); May cause staghorn calculi. • Uric acid (15%): radiolucent. • Cystine stones (1%). • Risk factors: • Decreased fluid intake especially in hot climates. • Hypercalcemia due to: hyperparathyroidism, bony destruction, multiple myeloma, sarcoidosis or prolonged immobilization. • Positive family history or personal past history. • Underlying GI Diseases (such as IBD). • Signs and symptoms: • Sudden onset of severe colickly flank pain which radiates to the groin (PATIENT IS RESTLESS!). • Nausea and vomiting. • Gross or microscopic hematuria. • Fever (±). • Diagnosis: • Urinalysis: looking for RBCs and WBCs. • KUB: 90% of stones are radiopaque. • Ultrasound: useful for those who must avoid radiation (pregnant females). • Test of choice: CT-scan without contrast. • Treatment: • Analgesia: NSAIDs or morphine. • IV fluids. • Most stones > 5 mm will pass spontaneously in adults. • For stones which will not pass spontaneously: extracorporeal shockwave lithotripsy, ureteroscopy with stone extraction or percutaneousnephrolithotomy. Urolithiasis

17. Urolithiasis

18. Epidemiology: incidence increases with age (90% in males < 80 years of age). • Cause: • Repetitive micro-injury to prostatic urethra → stimulating hyperplasia of cells in periurethral area → creating an adenoma which will cause obstructive urinary symptoms. • BPH occurs in transitional zone of prostate gland. • Hyperplastic tissue is composed of: glandular epithelium, smooth muscle and stroma. • Signs and symptoms: • Difficulty in initiating urination • Weak urine stream. • Postvoid dribbling of urine. • Sensation of incomplete emptying. • Complications: nocturia, overflow incontinence and urinary symptoms (urgency and frequency). • Diagnosis: • History (with classic signs and symptoms mentioned above). • Digital rectal examination feeling for prostate gland: enlarged, firm and smooth. • PSA. • Measurment of post-void residual urine volume. • Treatment: • Medical: • 5α-reductase inhibitors (e.g. finasteride): block the conversion of testosterone to dihydrotestosterone. • α-blockers: decreasing urethral resistance. • Surgical: • Small adenoma: transurethral prostatectomy. • Large adenoma: open simple prostatectomy. Common complications of these procedures are: retrograde ejaculation and incontinence. Benign Prostatic Hyperplasia (BPH)

19. Benign Prostatic Hyperplasia (BPH)

20. Definition: it is an adenocarcinoma and considered to be the most common malignancy in males in which the risk increases after the age of 50 years. It commonly occurs in the peripheral zone or prostate gland. • Signs and symptoms: • Nowadays, most patients are ASYMPTOMATIC at time of diagnosis due to widely spread screening with PSA. NOTICE THAT PATIENTS WHO TAKE 5α-REDUCTASE INHIBITORS WILL HAVE PSA REDUCED BY 50%. • Symptomatic patients: • Obstructive urinary symptoms (similar to those mentioned in BPH). • Bone pain (low back pain) if there is metastasis. • Diagnosis: • PSA: • Useful in detection of early prostate cancer. • It is not specific (why?) → because it can be elevated in: BPH or prostatitis. • PSA is usually used to follow-up patients and their response to treatment. • Digital rectal examination: feeling for prostate gland (hard, fixed and irregular). • Transrectal ultrasound to guide you for BIOPSY. • Metastasis: bone scan, CXR and abdomino-pelvic CT-scan. • Staging: • Metastasis occurs via: • Direct extension: bladder floor or seminal vesicles. • Lymphatics. • Hematogenous: axial skeleton. • Gleason grading system (histological grading): • 2: best prognosis. • 10: poorly differentiated tumor with the worst prognosis. • Treatment: • Androgen deprivation therapy: • Bilateral orchiectomy. • Estrogen administration. • Androgen synthesis inhibitor (ketoconazole). • GnRH agonists (leuprolide). • Radiation: complications include secondary malignancy, cytitis, urethritis, proctitis (diarrhea) and impotence. • Radical prostatectomy (removal of prostate, seminal vesicle and ampulla of vas):transabdominal, tranperineal, laparoscopic or robotics. Prostate Cancer

21. Prostate Cancer

22. Epidemiology: • Age: 50-60 years. • More common in males. • Originates from epithelium of proximal convoluted tubule of kidney. • Causes: • Smoking. • Exposure to asbestose, cadimium and solvents. • Translocation between chromosomes 3 and 8. • Signs and symptoms: • There is a classic triad (BUT IT IS ONLY PRESENT IN 10% OF PATIENTS): flank pain, palpable abdominal mass and gross hematuria. • Other systemic symptoms: anorexia, weight loss, anemia and intermittent fever. • Patients might have para-neoplastic syndromes (if tumor secretes hormones): • PTH-like substance: hypercalcemia. • ACTH: cushing’s syndrome. • Prolactin: galactorrhea. • Diagnosis: • Test of choice: CT-scan (both for diagnosis and staging). • Staging: • Stage-I: confined within the kidney. • Stage-II: invading capsule but not Gerota’s fascia. • Stage-III: involving lymph nodes, ipsilateral vein or IVC. • Stage-IV: distant metastasis. • Treatment: • No metastasis: radical nephroctomy (removal of kidney + adrenal gland + Gerota’s fascia). • Metastasis: palliation with radiation. Renal Cell Carcinoma

23. Renal Cell Carcinoma

24. Epidemiology: • More common in males (60-70 years of age). • Most common type: transitional cell tumor which results from smoking, dyes or exposure to chemicals. • Other types (with worse prognosis): • Squamous cell carcinoma which can be caused by indwelling catheter, recurrent UTIs or Schistosomiasis. • Adenocarcinoma: which is characterized by direct spread to uterus and large bowel. • Signs and symptoms: • Most common: gross/microscopic hematuria. • Others: dysuria, frequency, urgency or obstructive urinary symptoms. • Diagnosis: • Urine cytology. • Intravenous pyelography (IVP): shows filling defect. • Cystoscopy with biopsy of the tumor (best). • Staging: CT-scan of abdomen and pelvis. • Staging: • Superficial (Tis): carcinoma in situ. • Invasive: • T1: invading submucosa. • T2: invading muscularis. • T3: reaching perivesicle fat. • T4: invading adjacent structures. • Treatment: • Tis – T1: transurethral resection of bladder tumor followed by chemotherapy with BCG or mitomycin. • ≥ T2: radical cystectomy with resection of iliac lymph nodes. If patient is poor surgical candidate → radiation. Bladder Cancer

25. Bladder Cancer