SUG404 — Urology: Lecture Note

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la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Course code: SUG 404 Course title: Urology Course credit load: 2 Units Series 1: Obstructive Uropathy and Complications • Part 1.1: Urethral Stricture Disease o Sub Part 1.1.1: Anatomy of the urethra and aetiology of stricture o Sub Part 1.1.2: Clinical features and diagnosis of urethral stricture o Sub Part 1.1.3: Management of urethral stricture • Part 1.2: Benign Prostatic Enlargement o Sub Part 1.2.1: Anatomy and pathophysiology of benign prostatic enlargement o Sub Part 1.2.2: Clinical features and assessment of BPE o Sub Part 1.2.3: Management of benign prostatic enlargement • Part 1.3: Prostate Cancer o Sub Part 1.3.1: Epidemiology and risk factors of prostate cancer o Sub Part 1.3.2: Diagnosis and staging of prostate cancer o Sub Part 1.3.3: Management of prostate cancer • Part 1.4: Complications of Obstructive Uropathy o Sub Part 1.4.1: Upper tract obstruction and hydronephrosis o Sub Part 1.4.2: Obstructive renal failure o Sub Part 1.4.3: Urinary fistulae Introduction Imagine a man in his sixties who has noticed, over many months, that his urinary stream has become weaker, that he strains to empty his bladder, and that he now wakes several times a night to pass urine. This gradual, easily overlooked pattern of symptoms is one of the most common reasons for surgical consultation in men, and it sits at the heart of this Series: obstructive

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS uropathy, the range of conditions that narrow or block the outflow of urine, and the serious complications that follow when obstruction is left unrecognised or untreated. The aim of this Series is to equip you with the knowledge to recognise, investigate, and manage the common causes of obstructive uropathy and to anticipate and manage its complications. We shall commence this Series by examining urethral stricture disease, from its anatomical basis and causes through to diagnosis and management. Next, we will consider benign prostatic enlargement, covering its pathophysiology, clinical assessment, and the medical and surgical options for treatment. Following that, our attention turns to prostate cancer, addressing its epidemiology, diagnosis, staging, and management. Finally, we will conclude by examining the complications of obstructive uropathy, including hydronephrosis, obstructive renal failure, and urinary fistulae. Series Learning Outcomes Upon completing this Series, you should be able to: 1. SLO 1.1: describe the aetiology, diagnosis, and management of urethral stricture, 2. SLO 1.2: describe the pathophysiology, assessment, and management of benign prostatic enlargement, 3. SLO 1.3: describe the diagnosis, staging, and management of prostate cancer, and 4. SLO 1.4: describe the complications of obstructive uropathy and their management. 1.1 Urethral Stricture Disease 1.1.1 Anatomy of the urethra and aetiology of stricture The male urethra is divided into the anterior urethra (penile and bulbar segments, surrounded by the corpus spongiosum) and the posterior urethra (membranous and prostatic segments). A urethral stricture is a fibrotic narrowing of the urethral lumen from scar tissue replacing the normal elastic urothelium, most commonly affecting the bulbar urethra. Common causes in Nigerian practice include trauma (pelvic fracture, straddle injury), iatrogenic injury (prolonged or traumatic catheterisation, instrumentation), infection (particularly untreated or recurrent gonococcal urethritis), and, less commonly, balanitis xerotica obliterans or congenital stricture. Many cases remain idiopathic. Fill in the blank: A urethral stricture most commonly affects the ________ urethra. In Nigerian practice, a major infective cause of urethral stricture is untreated ________ urethritis.

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS 1.1.2 Clinical features and diagnosis of urethral stricture Clinical features include a progressively weak or split urinary stream, straining to void, incomplete bladder emptying, urinary frequency, and recurrent urinary tract infection. Longstanding strictures may progress to acute or chronic urinary retention, and complications include periurethral abscess and urethrocutaneous fistula if untreated. Diagnosis is confirmed by retrograde urethrography, which outlines the stricture's site, length, and severity, or by flexible cystourethroscopy, which allows direct visualisation. Uroflowmetry supports the diagnosis by demonstrating a flattened, plateau-shaped flow curve characteristic of urethral obstruction. Fill in the blank: Retrograde ________ is the standard imaging investigation for suspected urethral stricture. Uroflowmetry in urethral stricture classically shows a flattened, ________-shaped curve. 1.1.3 Management of urethral stricture Management options include optical urethrotomy (endoscopic incision of the stricture, suitable for short, single strictures with a reasonable success rate but a significant recurrence risk), intermittent self-dilatation to maintain patency after urethrotomy, and urethroplasty (surgical reconstruction), the gold standard for long or recurrent strictures. Urethroplasty techniques include excision and primary anastomosis for short bulbar strictures, and substitution urethroplasty using buccal mucosal grafts for longer strictures, offering the best long-term success rates. Suprapubic catheterisation may be required temporarily in acute retention until definitive treatment is arranged. Fill in the blank: The gold standard surgical treatment for a long or recurrent urethral stricture is ________. Substitution urethroplasty commonly uses a graft harvested from the ________ mucosa.

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Figure 1.1: Urethral anatomy and the site and effect of urethral stricture. Pilot questions 1.1 1. Describe the anatomical segments of the male urethra. (Linked to SLO 1.1) 2. List the common causes of urethral stricture in Nigerian practice. (Linked to SLO 1.1) 3. Describe the clinical features of urethral stricture. (Linked to SLO 1.1) 4. Describe the investigations used to diagnose urethral stricture. (Linked to SLO 1.1) 5. Compare optical urethrotomy and urethroplasty in the management of urethral stricture. (Linked to SLO 1.1) 1.2 Benign Prostatic Enlargement 1.2.1 Anatomy and pathophysiology of benign prostatic enlargement The prostate surrounds the proximal urethra and is divided into zones, with benign prostatic enlargement (BPE) arising predominantly from the transition zone. Hyperplasia of glandular and stromal tissue, driven by dihydrotestosterone, causes progressive enlargement, which mechanically and functionally obstructs urinary outflow as men age.

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Bladder outlet obstruction from BPE causes the detrusor muscle to hypertrophy and, over time, decompensate, leading to incomplete emptying, elevated post-void residual volume, and the risk of acute retention, upper tract dilatation, and secondary renal impairment if left untreated. Fill in the blank: Benign prostatic enlargement arises predominantly from the ________ zone of the prostate. Prostatic growth in BPE is driven by the hormone ________. 1.2.2 Clinical features and assessment of BPE Lower urinary tract symptoms (LUTS) from BPE are divided into voiding symptoms (hesitancy, weak stream, straining, incomplete emptying) and storage symptoms (frequency, urgency, nocturia), assessed using validated tools such as the International Prostate Symptom Score (IPSS), which also grades symptom severity and guides management decisions. Assessment includes digital rectal examination (assessing size, consistency, and symmetry), urinalysis to exclude infection or haematuria, serum creatinine to assess renal function, and prostate-specific antigen (PSA) where prostate cancer is a concern, alongside uroflowmetry and post-void residual measurement. Fill in the blank: Symptom severity in BPE is commonly assessed using the ________ score. Digital rectal examination in BPE typically reveals a smooth, ________ enlarged prostate. 1.2.3 Management of benign prostatic enlargement Medical management includes alpha-blockers (such as tamsulosin, relaxing prostatic smooth muscle for rapid symptom relief) and 5-alpha reductase inhibitors (such as finasteride, reducing prostate volume over months by blocking dihydrotestosterone conversion), often combined in men with larger glands. Surgical management is indicated for refractory symptoms, recurrent retention, renal impairment, or complications, with transurethral resection of the prostate (TURP) the gold standard, alongside newer techniques such as laser enucleation, and open prostatectomy reserved for very large glands where endoscopic access is unsuitable. Fill in the blank: The gold standard surgical procedure for benign prostatic enlargement is ________. Finasteride works by blocking the conversion of testosterone to ________.

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Figure 1.2: Prostate zonal anatomy and the management pathway for benign prostatic enlargement. Pilot questions 1.2 11. Describe the zonal anatomy of the prostate and its relevance to BPE. (Linked to SLO 1.2) 12. Distinguish voiding from storage lower urinary tract symptoms. (Linked to SLO 1.2) 13. Describe the components of clinical assessment of a patient with suspected BPE. (Linked to SLO 1.2) 14. Compare the mechanisms of action of alpha-blockers and 5-alpha reductase inhibitors. (Linked to SLO 1.2) 15. List the indications for surgical management of BPE. (Linked to SLO 1.2) 1.3 Prostate Cancer 1.3.1 Epidemiology and risk factors of prostate cancer Prostate cancer is one of the most common cancers in men and a leading cause of cancer death among Nigerian men, who tend to present at a later, more advanced stage than in high-income countries. Risk factors include increasing age, family history, and black African ancestry, which carries a notably higher incidence and more aggressive disease course.

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Most prostate cancers arise in the peripheral zone, in contrast to BPE, which explains why early cancer often causes no urinary symptoms and why digital rectal examination (feeling the posterior peripheral zone) remains a

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