NTIV_2017-18

Male Reproductive Disorders &

other Urological Disorders
Learning Objectives
Learning Objectives
To understand the male reproductive system
To list out the male reproductive disorders
To explain the investigations and the diagnostic
tests
To understand the treatment plan and health
education
To understand the urinary incontinence, the
investigations and the treatment
To understand the treatment plan of bladder
cancer
Functions of the male reproductive system
Organ Function
1. Penis a. Conduit for urine bladder
b. Male organ for sexual intercourse
2. Scrotum a. House testes and maintains their temperature at a
level cooler than the body thus promoting normal
sperm formation
3. Testes a. Endocrine glands that secrete the primary male
hormone, testosterone
4. Epididymis a. Storage for some sperm
b. Final sperm maturation
c. Where sperm develops the ability to be motile
5. Vas Deferens a. Storage of sperms
b. Conduction of sperm from epididymis to urethra
6. Seminal Vesicle, prostate, a. Secretion of seminal fluids that carry sperm and
Bulbourethral gland provide for:
- Nourishment of sperm
- Protection of sperm from hostile acidic environment
of vagina
- Enhancement of motility of sperm
- Washing of all sperm from urethra
Performing the GU Exam

Inspect and palpate the penis Possible findings

• Development of penis and • Sexual maturation, rashes, scabies
surrounding hair

• Foreskin (retract if present) • Phimosis (cannot be retracted over

glans)
• Glans • Ulcers, scars, nodules or
inflammation
• Urethral meatus
Note any discharge • Urethritis
Performing the GU Exam
Inspect & palpate the scrotum
• Skin of scrotum
• Contours of scrotum
Possible findings
• Rashes, inflammation
• Swellings or bulges (hernia or
hydrocele)
• Cryptorchidism (undescended
testes)

Transillumination, atechnique
in which a light source is
applied to the side of a
scrotal enlargement, is
useful in determining the
nature of a scrotal mass.

http://www.meddean.luc.edu/lumen/MedEd/uro
logy/hydrchx2.htm
Source: Jarvis, C. (2012).Physical Examination &
Health Assessment (6th ed). St. Louis: Elsevier
 Scrotal disorder – Hydrocele and Varicocele

(Swartz, 2002, p. 484)

Performing the GU Exam

Palpate Possible findings

• Testis • Orchitis, torsion
Note tenderness • Lumps (cancer)

• Epididymis • Swelling or lumps (cysts, tumors, or

Note tenderness epididymitis)

• Spermatic Cord and adjacent area • Varicocele (“bag of worms”)

Source: Jarvis, C. (2012).Physical Examination & Health Assessment (6th ed). St. Louis: Elsevier
Performing the GU Exam
Inspect
• Inguinal and femoral areas
Instruct patient to cough or
to bear down
Palpate
• External inguinal ring
through scrotal skin
• Instruct patient to cough or
to bear down
• Lymph nodes
Possible findings
• Sudden swelling in
scrotum (hernia or mass)
• Pain during cough or strain
should be evaluated
• Direct hernia (felt on pad of
examining finger)
• Indirect hernia (auscultate
for bowel sounds)
• Enlarged nodes (infective
or malignant disorders)
Source: Jarvis, C. (2012).Physical Examination & Health Assessment (6th 12
ed). St. Louis: Elsevier
Inguinal & femoral hernia

Hernia
– Inspection
• Inguinal region (no
bulge)
– Palpation
• Inguinal canal
• Femoral area

13
Digital Rectal Exam: Possible Findings
(adopted from www.brown.edu/Research/ICHP/Modules/Mod8DRE/.../DRE.ppt )

Normal prostate
• About 2.5 cm from side to side
• Prominent median sulcus (groove that separates the two lobes)
• Consistency is rubbery and smooth
• Tenderness not usual, but patients should feel urge to urinate
when you palpate

National Cancer Institute

Digital Rectal Exam: Possible Findings
(adopted from www.brown.edu/Research/ICHP/Modules/Mod8DRE/.../DRE.ppt )

Benign Prostatic Hypertrophy (BPH)

• Enlargement of gland is symmetrical
• Marked protrusion into rectal lumen
• Smooth with no nodularity
• Median sulcus may be indistinguishable
• Consistency is rubbery, ‘boggy’ or slightly elastic
Digital Rectal Exam: Possible Findings
(adopted from www.brown.edu/Research/ICHP/Modules/Mod8DRE/.../DRE.ppt )

Prostate Cancer
• Asymmetric shape
• Hard consistency
• Discrete nodule may be palpable
• Median sulcus often obscured

Note: Hard areas of prostate are not always cancerous but

may indicate conditions such as prostatic stones or
chronic inflammation
Digital Rectal Exam: Possible Findings
(adopted from www.brown.edu/Research/ICHP/Modules/Mod8DRE/.../DRE.ppt )

Acute prostatitis
• Gland is swollen
• Firm consistency
• Very tender to touch
• Examine the gland carefully
• Pay attention to patient’s verbal and nonverbal cues
Concluding the Male GU Exam
• Explain your findings to the patient
• Individualize a follow-up plan for the patient
– Recommended interval for next physical exam
– Cancer screening tests—sigmoidoscopy or colonoscopy; PSA if
appropriate (ACS Recommendation)
• Address patient concerns and understanding
• Young adult males (< 35 years)
– Sexuality, including safe sexual practices
– Self-care, including the testicular self-exam
• Older adult males (40+ years)
– Prostate and colorectal cancer screening
– Sexual function
– Lower urinary tracts symptoms that affect quality of life (e.g.,
incontinence)
Common Chief Complaints

• Scrotal pain
• Penile lesion (STIs)
• Urethral discharge (STIs)
• Testicular mass (r/o CA)
• Erectile dysfunction (ED)
History taking before physical exam
• HPI - Treatment, trauma, fertility
• PMHx – partner with STIs
• Sx of genitourinary system
• Chronic – DM, Renal, heart, hepatic disease & circulatory system
• FHx – infertility; prostate, testicular or penile CA; hernia (feel
heavy in abd)
• Personal & Social Hx – exercise, ETOH, illicit drug; do they lift a
lot?
 Cont’d Hx

Sexual Hx:
• sexual practice
• Orientation – who & what do they have sex with?
• # partners (current & lifetime)
• # partners in past 6 months track exposure for follow up tx
• Form of contraception
 Risk factors

• Penile – lack of circumcision

• Testicular – cryptorchidism (undescended testicle) with elevated
testicular temp
• Urethral – hyperspadias – corrective surgery for boy at infancy
• Scrotum – if noted swelling/inflammation with the side lower on left
testes
What are typical to look for during male exam?

• Testicular torsion – twisted testes – EOT

• Testicular CA – non-illumination
• Epidydimitis - by elevating scrotum with immediate relieve of
discomfort (confirm Dx)
• Hernia – sensation of fullness or heaviness in scrotum
• Hear bruit for tumor (due to vascularity of cancer cells) or go by
transillumination
Testicular Torsion
• Chief complaint: presented with acute testicular
pain, exacerbated by sitting, running and sex
• Occurs when a testicle is mobile and the
spermatic cord twists, cutting off the blood supply
• Acute scrotal swelling and severe pain as blood
supply to testicles is interrupted
• An emergency requiring immediate surgical
intervention where spermatic cord is untwisted
and the testicle is immobilized by suturing to
scrotum– need EOT otherwise infertility
• Without prompt surgery (within 6 hours as
possible), the testicle may atrophy or develop
abscess, and if it turns necrotic, removal is
needed
Source: Next Magazine (4 July 2013)
Testicular Cancer
• Most common and serious solid tumor cancer in men between
15 and 35 years of age
• Family hx, exogenous estrogen and cryptorchidism
(undescended testicles) are known risk factors
• The male offspring of women who used estrogen in the form
of diethylstilbestrol (DES) to prevent spontaneous abortion
during first trimester of pregnancy are at greater risk for
testicular cancer
• Testicular cancers are germ cell tumors and are divided into
two main types: seminomas & nonseminomas.
• Seminoma tumors are more sensitive to radiation.
• Non-seminoma tumors are more aggressive and likely to
spread to other parts of the body.
Lawes, 2011
Clinical manifestations of Testicular CA

• Painless enlargement in the testicle

• Metastasis to retroperitoneal lymph nodes (lymphatic spread)
include back pain, vague abd pain, nausea & vomiting, bowel and
bladder changes, anorexia and weight loss
• Distant metastasis occurs most commonly to the lungs and cough,
dyspnea and hemoptysis are noted
Management of Testicular CA

• Radical orchiectomy ice bag and scrotal support upon

ambulation
• Radical inguinal orchiectomy with retroperitoneal lymph node
dissection (for stage I nonseminoma)
• Radiation therapy of perineum and pelvis
• Chemotherapy
Testicular Self-Examination (TSE)

• Monthly testicular exam recommended

• Starting from 13 – adulthood
• High risk for testicular cancer:
– 15-40 years old
– White
• T: Timing, once a month
• S: Shower, warm water relaxes scrotal sac
• E: Examine, check for changes, report changes immediately
 Epididymitis
• Infections in urethra, prostate or bladder can spread
along the vas deferens
• Complication of catheterization or transurethral
surgeries (↓due to prophylactic abx)
• Almost always unilateral; swelling, reddened & painful
 Ultrasound to assess the blood supply which will
note an increase in blood supply
• Older man – urinary pathogens; young man – STI; 
Check UA and C & S/T to r/o STI; yet to r/o UTI for
men > 50 y/o;
• If not STIs nor UTI, could be a runner in causing the
epididymitis as trauma is noninfectious cause
Phimosis & Paraphimosis
• Phimosis occurs when the penile foreskin
(prepuce) is constricted at the opening, making
retraction difficult or impossible
• Paraphimosis occurs when a tight foreskin, once
retracted, cannot be returned to its normal
position
• Can be congenital or a result of inflammation,
infection, or local trauma
• Assess for edema, erythema, tenderness, and
purulent discharge
• Intervention includes controlling local infection
with antibiotics; effective genital hygiene; or
circumcision may be necessary
Lawes, 2011
Benign Prostate Hypertrophy & Ca Prostate
It is introduced at the Case 3 group presentation.
• TURP is still the mainstream approach in Hong Kong for severe
cases of BPH rather than the laser or vaporization technique due
to cost containment and same effectiveness

• American Cancer Society (ACS) – Watchful Waiting concept

• PSA is not recommended routinely per ACS
• check PSA with life expectancy at least 10 yrs  rationale:
tends to be slow growing; >4.0 ng/ml  r/o prostate CA
Watchful waiting should include:
 Education
 Reassurance
 Periodic monitoring
 Lifestyle advice
Prostate-specific antigen (PSA)
• All men have a small amount of PSA in their blood. The level of
PSA rises with age.

The accepted normal PSA test result is :

1. ≤ 2.8 ng/ml for men aged in their 50s
2. up to 4 ng/ml for men aged in their 60s.
3. For men in their 70s, a PSA of up to 5.3 ng/ml can still be normal
(Watson et al, 2002)

• An increased level of PSA can indicate a prostate problem; The

PSA level can be affected by BPH, prostatitis and recent vigorous
exercise, ejaculation, prostate biopsy or DRE.
PSA value with Interpretation (Materials adopted from Dr K.M. LAM)
 < 4 ng/ml (~ 8% cancer)
 4-10 ng/ml (~ 20-25% cancer)
(Millward, 2006)
 > 10 ng/ml (> 50% cancer)
DRE & Transrectal Biopsy

DRE
Prostate Heath Index (PHI)

• http://prostatehealthindex.org/

• http://www.health.harvard.edu/blog/harvard-expert-urges-caution-
for-use-of-new-prostate-cancer-test-201207024990
Treatment for Ca Prostate

Watchful waiting or active surveillance

Surgery : radical prostatectomy, pelvic
lymphadenectomy, TURP
Radiation therapy and radiopharmaceutical
therapy
Hormone therapy
Chemotherapy
Biologic therapy
Bisphosphonate therapy
Source: National Cancer Institute
Two types of radical prostatectomy. In a retropubic prostatectomy, the prostate
is removed through an incision in the wall of the abdomen. In a perineal
prostatectomy, the prostate is removed through an incision in the area
between the scrotum and the anus.
 Lower urinary tract symptoms (LUTS)

Obstructive Irritative
Weak stream Urgency
Straining Frequency
Incomplete emptying Nocturia
Prolonged voiding Urge incontinence
Hesitancy Small voided volume
Terminal dribbling
retention

Materials adopted from Dr K.M.LAM / TKOH

 Pathway to diagnose BPH
LUTS

Benign Prostatic Enlargement (BPE) Other causes

(By DRE & US)

Bladder Outlet Obstruction (BOO)

(By Urodynamic study)

BPH (Pathology) Ca Prostate Other causes

(Pathology)
Materials adopted from Dr K.M.LAM / TKOH
Lifestyle modifications nurses can teach for
men with BPH

• Patient with BPH must avoid taking pseudoephedrine

(Sudafed or Fedac) nasal decongestant  at risk of
AROU
• ↑Younger patient (age 30-40) with enlarged
prostate symptoms
• Diet – soy products from soy beans and lycopene
from cooked tomato; encourage more fruits &
vegetables
 Medical treatment for symptomatic BPH
• First line alpha blocker: Terazosin 2-6mg nocte (titrate according
to symptom)
• Second line alpha blocker (when patient does not tolerate side
effects of first line medication): Tamsulosin OCAS (Harnal OCAS)
0.4mg daily, Doxazosin GITS (Cardura XL) 4-8mg daily (titrate
according to symptom) or Alfuzosin PR (Xatral XL) 10mg daily
• 5 alpha reductase inhibitor: Finasteride (Proscar) 5mg daily;
usually given as combination therapy with alpha blocker; indicated
in patient with prostate > 40ml & very high risk for surgery

Materials adopted from Dr K.M.LAM / TKOH

Effects of alpha blocker

• Improve most symptoms of BPH

• Effective in around 60% of patients
• Result in postural hypotension in 2-5% of patients (normotensive
patients not significantly affected)
• Usually require gradual dose titration
• α adrenoceptor blockers improve lipid profile, reduce platelet
adhesiveness and may improve erectile function

Terazosin (Hytrin): once per day

Doxazosin (Cardura XL): once per day
Alfuzosin (Xatral SR): twice per day
Tamsulosin (Harnal): once per day
5-alpha reductase inhibitors

• 5 alpha reductase converses testosterone to dihydrotestosterone

which is a more active metabolite to stimulate prostate growth.
• Bothe can alter the AROU and OT rates
• Men with small prostate are less likely benefit.
• Combination of a 5 alpha reductase inhibitor with an alpha blocker
seems beneficial
• Decreases serum PSA by 50% within 6 months
• Treatment with 5 alpha reductase inhibitors does not mask the
detection of prostate cancer. By doubling PSA serum levels, an
accurate estimation can be expected.
• Side-effects minimal
Surgery should be considered for those men

• Moderate / severely bothered by LUTS, and failed medical

treatment
• Bothersome LUTS, who not want medical treatment but request
active intervention
• With strong indication for surgery

Surgery treatment for BPH

Transurethral resection of the prostate (TURP)
Transurethral incision of the prostate (TUIP)
Transurethral electrovaporization of the prostate (TUEVP)
Complications of TURP

Intra-operative postoperative
• Bleeding • Bladder tamponade
• Balloon compression • Infection
• TUR syndrome • Urinary retention
• Extravasation • Incontinence
• Injury of orifices • Urethral stricture
• Injury of external sphincter • Bladder neck stenosis
• Retrograde ejaculuation
• Erectile dysfunction
• Recurrent BPH
• Associated morbidity and
(Rassweiler, Teber, Kuntz & mortality
Hofmann, 2006)
TURP Syndrome (Gupta, 2009)

• It is an iatrogenic complication caused by absorption of the

irrigating fluid which is used to distend the bladder during surgery.
• It can occur within 15 minutes after resection starts or up to 24
hours postoperatively.
• It occurs due to acute changes in: intravascular volume, plasma
sodium concentration and osmolarity.
Presentation of TURP syndrome:
1.Bradycardia
2.Hypertension / hypotension
3.Elevated CVP
4.Angina
5.ECG changes
6.Seizures, confusion or coma
Management of TURP syndrome (Gupta, 2009)
If TURP syndrome is suspected:
 Surgery must be stopped
 IV fluids should be stopped
 Airway & breathing
 Circulation – bradycardia & hypotension should be treated with
glycopyrrolate & vasopressors
 Seizures should be treated with anticonvulsants (e.g. diazepam, lorazepam
etc.), IV magnesium
 Investigations – check Na, osmolarity and Hb
 Diuretics is only recommended if there is acute pulmonary edema
 Severe hyponatremia (Na < 120mmol/L) & hypotension should be treated by
increasing extracellular fluid (ECF) tonicity in order to shift water from
intracellular fluid (ICF) to ECF, thus ameliorating cerebral edema.
• Hypertonic saline (3%) in those with normal renal function
• Hemofiltration if the patient has chronic renal failure
• 8.4% NaHCO3 can be used if hypertonic saline is not available
Urinary Incontinence (UI)
Definition: Involuntary loss of urine, which is a social or hygiene
problem, and which is objectively demonstrable
Stress urinary incontinence (Urethra underactivity) 壓力性
• Leakage of urine, with activities that increase abdominal pressure
Urge urinary incontinence (Overactive bladder) 急切性
• Loss of urine, with urge to urinate and yet inability to postpone
voiding
Overflow urinary incontinence 滿溢性
• Leakage of urine, at greater than bladder capacity; associated with
incomplete bladder emptying, due to either impaired detrusor
contractility or bladder outlet obstruction
Functional urinary incontinence
• can be result of physical, psychological or pharmacologic
Functional classification of UI

Abnormality Type of clinical incontinence

Bladder overactivity Urge
Bladder underactivity Overflow
Urethra overactivity Overflow

Urethra underactivity Stress

Rovner & Wein, 2004

Diagnostic testing

Black, Hawks, Keene &

Luckmann , 2009
Measuring urine flow rate
What to look for when interpreting uroflowmetry?

Voided volume: whether representative ( usually > 150 ml)

Measured scale on the tracing
Measure flow rate (Qmax)
Voiding time
The shape of the curve
- Overall configuration
- Amplitude variations within the flow
- Any return to baseline (interpretation)
- Post-void dribble
- Artifacts (check numeral values for accuracy)
Residual volume from bladder scanning
Uroflowmetry
Uroflowmetry study

Urine max flow rate (normally 20 - 25 ml/sec and age-specific)

Table 4 :Mean maximum and average flow rate parameters in different age group (adopted from
http://www.indianjurol.com/article.asp?issn=0970-1591;year=2009;volume=25;issue=4;spage=461;epage=466;aulast=Kumar)
Urodynamic study

• Aim: look for functional abnormality of lower urinary tract

Common indications:
- Overactive bladder syndrome fails behavior modification &
medical treatment
- Urge incontinence fails medical treatment, develops complication
or seeks for surgical treatment
- Stress incontinence fails behavior modification & pelvic floor
exercise or seeks for surgical treatment
- Neurogenic bladder
Urodynamic findings in normal voiding vs
BPH and Detrusor Overactivity

Urodynamic findings in normal voiding, benign prostatic

obstruction (BPO), and idiopathic detrusor overactivity (Thorpe & Neal, 2003)
(IDO)
Treatments of UI (Rovner & Wein, 2004)

Pelvic floor muscle training

 Strengthen pelvic floor muscles
Electrical stimulation
 External application of electrical current to the pelvic floor
Bladder training and behavioral training
 Use of a frequency / volume chart or voiding log plays a central role in
bladder training
(Female) Intravaginal supportive devices
 Pessaries, especially in patients with mild to moderate anterior vaginal wall
prolapse
Fluid intake and dietary changes
 Coffee, tea and alcohol should be avoided
Surgery
 Sling procedures, bladder neck suspension, artifical urinary sphincter
Medications
Bladder catheter valve

Open for drainage Closed

Benefits of catheter valve
• Your bladder will be used to store urine which is then
drained via the catheter. It is very important that you open
the valve and empty your bladder when you feel the need
to pass urine or at least four hourly. Do not leave your
bladder overfull.
• The use of a catheter valve provides very discreet catheter
management; you may feel more comfortable when
wearing close fitting clothes, for swimming or when
sexually active. Using a valve will allow the bladder to fill
and therefore help retain bladder tone, this is important if it
is planned for you to have the catheter removed at a future
date.
source: http://www.esht.nhs.uk/EasysiteWeb/getresource.axd?AssetID=399310
Neuromuscular stimulator

Controlled by
patient only

For patient who cannot perform pelvic floor exercise !

Female: insert to vagina, Male: insert to anus
Different surgeries for UI
Electrical stimulation : Bladder neck suspension for
sacral nerve stimulation stress incontinence
Medications for urinary incontinence (Leung, 2005)
For symptomatic urge incontinence:
o Anticholinergic agents
 oxybutynin 2.5 – 5 mg mg TDS (S/E: dry mouth)
 tolterodine 1-2 mg BD (S/E: dry mouth)
 solifenacin (vesicare) 5-10 mg QD (no dry mouth)
o Imipramine (tricyclic antidepressants)
 75mg QD (limited usage in older patients as this medication shares
the toxic effect on the heart)

For stress incontinence:

• alpha agonists
• Oestrogen
For patient with bladder outlet obstruction: Alpha blocking agents
Summary of medication for urinary problems
(available in HA)
Drugs for urinary retention
 Alfuzosin HCL Prolonged Release <Xatral XL> 10mg
 Distigmine Bromide <Ubretid> 5mg
 Doxazosin (Mesylate) Gits <Cardura XL> 4mg / 8mg
 Prazosin (HCL) <Minipress> 1mg / 2mg
 Tamsulosin HCL Prolonged Release <Harnal OCAS> 0.4mg
 Terazosin HCL <Hytrin> 1mg / 2mg / 5mg
Drugs for urinary frequency, enuresis & incontinence
 Amitriptyline HCL <Saroten> 10mg / 25mg
 Imipramine HCL <Tofranil> 25mg
 Nortriptyline (HCL) <Nortrilen> 10mg / 25mg
 Oxybutynin HCL <Ditropan> 5mg
 Propantheline Bromide <Probanthine> 15mg
 Solifenacin Succinate <Vesicare> 5 mg / 10 mg
 Tolterodine Tartrate <Detrusitol> 2mg
青瓜變豆腐 身體響警號

Source: Mingpao, 9 Sept 2013

Erectile Dysfunction (ED)

• Erectile dysfunction is defined as the persistent inability to

attain and maintain an erection sufficient enough to permit
satisfactory sexual performance.
• The term impotent is used mainly when describing men
who experience erectile failure during attempted
intercourse more than 75% of the time.
• A normal penile erection is caused by one or two main
mechanisms: reflex erection or psychogenic erection.
• Increasing age is the main risk associated with developing
ED.
Belavic, 2010
 Causes of Erectile Dysfunction

Belavic, 2010
Medical Treatments for ED
1st line treatments – Phosphodiesterase 5 (PDE5) inhibitors:
- Sidenafil (Viagra) ~ short half-lives (4-6 hrs)
- Vardenafil (Levitra) ~ short half-lives (4-6 hrs)
- Tadalafil (Cialis) ~ half-lives (16-18 hrs)
PDE5 inhibitors work by blocking PDE5 action so that cyclic
guanosine monophosphate (cGMP), a chemical produced during
sexual stimulation, continues its role in keeping the penis erect.
PDE5 inhibitors work only in the presence of sexual stimulation.
All these medications are effective 30 to 60 minutes after a dose.
 Alprostadil (Caverject) (2nd line treatment) is available as both an
intracavernous injection and a transurethral formulation.
Special precautions for taking PDE5 inhibitors

• Specific dosing recommendations for those with hepatic or renal

impairment and elderly patients
• No interaction between PDE5 inhibtors and the use of alcohol,
however, if the client consumes large quantities of alcohol which
can increase the risk of orthostatic hypotension (increased heart
rate, decreased standing BP, dizziness and headache).
• Don’t take nitrates (e.g. nitroglycerin) with PDE5.
• Sidenafil & Vardenafil users may experience changes in color
vision especially seeing objects and surroundings as being blue-
green in color.

Belavic, 2010
Bladder cancer
Risk factors:
 Cigarette smoking
 Occupations r/t dye (hair dressers) and long haul driver (limited toileting
facility)
 Aromatic amine exposure (rubber and chemical industry)
 Polycyclic aromatic hydrocarbon (coal and aluminum industry)
 Family history
 Chronic bladder infection
 Chronic indwelling bladder catheter / inflammation
 Signs and symptoms
 Painless hematuria (occurring in 85% of patients)
 Changes in urinary pattern, including frequency, the feeling of urgency, or
the inability to urinate
 AS the cancer progress, the patient may begin to have frank pain, weight
loss, leg edema, pain on urination and lower back pain
Investigations

• Physical examination
• Urine cytology (sensitivity: around 60%, specificity: over 90%)
• Cystoscopy (Gold standard)
• IVP
• CT
Flexible cystoscopy

• Aim: look for structural lesion of lower urinary tract

Common indications:
- Gross / microscopic haematuria
- Bladder cancer surveillance
- Storage / irritative lower urinary tract symptoms (LUTS)
- Urethral structure
Conditions that usually do NOT require flexible cystoscopy for
diagnosis
- BPH
- Urinary tract infection
- Urinary incontinence
 Treatments

BCG Intravesical immunotherapy for 6 weeks (for the cancer is

superficially confined to the first layer of the bladder wall)
Chemotherapy & radiation therapy ( the goal for reducing the chance
of cancer recurrence)

When the cancer is in the later stages, surgical intervention is required.

Cystectomy
(partial: removal part of the bladder; radical: removal of the bladder,
surrounding lymph nodes, part of the urethra, and nearby organs that
may contain cancer cells)
Transurethral resection with fulgurations
(Fulguration involves inserting a cutting or high-frequency electrical
tool thorough the urethra to remove or burn the cancer cells away.
Urinary diversion
Urinary Diversion
Cutaneous urinary diversion
 the ileal conduit in which a passage (conduit) is created using the
patient’s intestines
 the urine is diverted through a stoma on the abdominal wall and
collected in an external pouch
Stoma care
• Similar with colostomy care
• Beware of the surrounding skin
condition
• Mucus discharge care
• Overnight drainage
• Encourage fluid intake otherwise
the alkaline crystal may be formed
at the surrounding skin.
• Encourage 2L of fluid per day
Urinary Diversion (cont’d)
Continent urinary diversion
 internal reservoir used to collect urine
The neobladder (it is created using the patient’s small intestine,
which is formed into an internal pouch, placed at the same
position of the original bladder; and connected to the patient’s
urethra. The goal is to empty the neobladder by voiding in a
natural manner. It is considered a bladder substitute. Patients
should beware of urinary incontinence & accidental leakage.)

The continent ileal reservoir / Kock pouch ( it is created using the

patient’s small intestine to create an internal pouch, connected to
the ureters, and attached to a stoma on the abdominal wall. The
patient with a Kock pouch must be taught how to drain the pouch
by self – catheterization and also how to care for the stoma.
Kock Pouch

Barlow & Shepard, 2014

Types of incontinent diversions
Types of continent diversions
Urostomy

Description ileal conduit (most common); ureters attached to

sectioned segment of ileum and sutured to skin
surface

Common disease Bladder cancer, neurogenic bladder

process
Location of stoma Right lower abdominal quadrant
Appliance-pouch system Pouch with antireflux and drain valve; connected to
bedside collector when sleeping
Effluent Urine & mucus
Appliance emptying 3 to 6 times per day
Special considerations Drink cranberry juice; report foul odor

Piras & Hurley, 2011

Scemons, 2013
References
References (cont’d)
• Barlow, W. & Shepard, L.H. (2014). Care of the patient with bladder
cancer. Nursing Made Incredibly Easy, 12(5): 40-48.
• Belavic, J.M. (2010). A look at erectile dysfunction drugs. Nursing
Made Incredibly Easy, 8(1): 13-15.
• Black, J.M., Hawks, J.H., Keene, A. & Luckmann, J. (2009).
Medical-surgical nursing: Clinical management for positive
outcomes (8th ed.). Philadelphia: W.B. Saunders Company.
• Gupta, R. (2009). Anesthesia for transurethral resection of the
prostate. Retrieved on 13 Nov 2010 from
http://totw.anaesthesiologists.org/wp-content/uploads/2009/10/155-
Anaesthesia-for-Transurethral-resection-of-the-prostate-TURP1.pdf
• Hospital Authority. (2003). Clinical guidelines on geriatric urinary
incontinence.
• Lawes, R. (2011). The ABCs of male reproductive cancer. Nursing
Made Incredibly Easy, 9(4): 28-38.
References (cont’d)

• Leung, M.F. (2005). Urinary incontinence in geriatric patients.

The Hong Kong Medical Diary, 10(9): 7-9
• Patel, A.R. & Campbell, S. (2009). Current trends in the
management of bladder cancer. JWOCN, 36(4): 413-421.
• Piras, S.E. & Hurley, S. (2011). Ostomy care: are you prepared?.
Nursing Made Incredibly Easy, 9(5): 46-48.
• Rassweiler, J., Teber, D., Kuntz, R. Hofmann, R. (2006).
Complications of transurethral resection of the prostate (TURP) –
incidence, management, and prevention. European Urology, 969-
980.
• Rovner, E.S. & Wein, A.J. (2004). Treatment options for stress
urinary incontinence. Urinary Incontinence in Women, 6(3): S29 –
S47.
• Scemons, D. (213). The ins and outs of ostomy management.
Nursing Made Incredibly Easy, 11(5): 32-42.