This document discusses lower urinary tract disorders, including both congenital and acquired conditions of the bladder, urethra, and prostate. It describes several congenital defects such as bladder exstrophy, posterior urethral valves, hypospadias, and epispadias. It also discusses acquired conditions like lower urinary tract infections and urethral strictures. Urethral strictures can be caused by infections, trauma, instrumentation, or surgery and present with obstructive or irritative voiding symptoms. Investigations and management options for urethral strictures include urethroscopy, dilation, internal urethrotomy, or urethroplasty surgery.

1. LOWER URINARY TRACT
DISORDERS
HABAKUK LARRY OMONDI

2. Introduction
• Lower urinary tract composed of – bladder,
urinary sphincter and urethra and prostate.
• Can be congenital disorders or acquired
disorders e.g infections, tumours e.c.t

3. anatomy

4. Congenital defects of lower
urinary tract
Bladder exstrophy
• occurs in 1:50 000 births (male–female ratio 4:1). In the male, the penis is broad
and short, and bilateral inguinal herniae may be present. In epispadias alone, the
pubes are united and external genitalia are almost normal, although in the female
the clitoris is bifid
Treatment
• The bladder is closed in the first year of life, usually following osteotomy of both
iliac bones just lateral to the sacroiliac joints.
• Later, reconstruction of the bladder neck and sphincters is required. In some
patients the reconstructed bladder remains small and requires augmentation
• Long-term complications include:
(1) stricture at the site of anastomosis with bilateral hydronephrosis and infection; (2)
hyperchloraemic acidosis; and
(3) an increased (20-fold) risk of tumour formation (adenoma and adenocarcinoma) at
the site of a ureterocolic anastomosis.

5. Posterior urethral valves
• These folds of urothelium cause obstruction to the urethra of boys. They
are usually just distal to the verumontanum but they may be within the
prostatic urethra. They are flap valves and so, although urine does not flow
normally, a urethral catheter can be passed without difficulty.
• Dilatation of the urinary tract now commonly leads to diagnosis by
ultrasound scanning before birth.
• Other cases present with urinary infection in the neonatal period.
• Sometimes the valves are incomplete and the patient is symptom free until
adolescence or adulthood. Posterior urethral valves need to be detected and
treated as early as possible to avoid the development of renal failure.

6. • If the bladder is filled with contrast medium, the dilatation of
the urethra above the valves can be demonstrated on a voiding
cystogram. The bladder is hypertrophied and often shows
diverticula.
• Typically, there is vesicoureteric reflux into dilated upper
tracts
Treatment
• A suprapubic catheter is inserted to relieve the back pressure
and allow the effects of renal failure to subside before
definitive treatment by transurethral resection of the valves.

7. Hypospadias
• occurs in one in 200–300 boys and is the most common congenital
malformation of the urethra. It is a condition in which the opening
of the urethra is on the underside of the penis, instead of at the tip.
• The external meatus opens on the underside of the penis or the
perineum, and the ventral aspect of the prepuce is poorly developed
(‘hooded prepuce’).
• Hypospadias is classified according to the position of the meatus:
• Glanular hypospadias. This is common and does not usually require
treatment.
• Coronal hypospadias.
• Penile and penoscrotal hypospadias.
• Perineal hypospadias. This is the most severe abnormality

9. Treatment
• Glanular hypospadias does not need treatment unless the meatus is
stenosed, in which case a meatotomy is performed. Surgery is indicated
for other forms of hypospadias to improve sexual function, to correct
problems with the urinary stream and for cosmetic reasons.
• A variety of plastic surgical procedures is described to correct the
chordee and to re-site the urethral opening.
• The ideal age for surgery is 6–12 months.
Epispadias
• very rare. Congenital condition in which the urethra opens on dorsal
surface of penis
• In penile epispadias, the opening on the dorsum is associated with
upward curvature of the penis. Epispadias usually coexists with
bladder exstrophy and other severe developmental defects.

10. Lower urinary tract infections
Definition
 UTI- symptomatic presence of microorganisms within the
lower urinary tract.
 Uncomplicated: UTI without underlying renal/ neuro dse
 Complicated: UTI with underlying structural, medical or
neuro dse
 Recurrent: >3 symptomatic UTIs in 12 months following
clinical therapy
 Reinfection: Recurrent UTI caused by diff pathogen at any
time
 Relapse: recurrent UTI caused by same species causing
original UTI within 2wks after therapy

11. Etiology
Enteric, usually gram-negative aerobic bacteria (most
often)
• Escherichia coli : 75 to 95% of cases.
• Klebsiella
• Proteus mirabilis
• Pseudomonas aeruginosa.
Gram-positive bacteria (less often)
• Staphylococcus saprophyticus is isolated in 5 to 10% of
bacterial UTIs.
• Enterococcus faecalis (group D streptococci)
• Streptococcus agalactiae (group B streptococci)

12. • In hospitalized patients, E. coli accounts for
about 50% of cases. The gram-negative
species Klebsiella, Proteus, Enterobacter,
Pseudomonas, and Serratia account for about
40%, and the gram-positive bacterial cocci, E.
faecalis, S. saprophyticus, and Staphylococcus
aureus account for the remainder

13. Pathophysiology
3 main mechanisms responsible for UTIs:
• Colonization with ascending spread
• Hematogenous spread
• Periurogenital spread
Bacterial virulence
Adhesins- E coli infection, these include both pili
(ie, fimbriae) and outer-membrane proteins.
Protection from immune system - capsular
polysaccharides, hemolysins, cytotoxic
necrotizing factor (CNF) protein

14. Host factors
I. Sex – females have short urethra
II. Age – common in extremes of age
III. Immune competency
IV.use of catheters not drained to gravity
V. Antibiotic use
VI.comorbidities – diabetes mellitus, spinal
injury, stroke.

15. Clinical Presentation
History
frequent chief complaint related to urinary tract infection (UTI) are
dysuria, urinary frequency, lower abdominal discomfort and urgency
• Urethral / vaginal discharge.
• Nocturia, gross hematuria, any changes in the color and/or
consistency of the urine
• Urinary tract abnormalities - Personally and within their families
• Comorbid conditions - Eg, diabetes
• Human immunodeficiency virus (HIV) status
• Immunosuppressive treatments for other conditions - Eg, prednisone
• Any previous surgeries or instrumentation involving the urinary
tract
• Fevers, chills, and malaise
• Sexual history

16. Physical Examination
• The patient appears uncomfortable but not
toxic. Ingunal lymphadenopathy.
• Vitals – fever, tachycardia and tachypnea
• suprapubic tenderness
• Pelvic examination - to exclude vaginitis,
cervicitis, or pelvic tenderness
• external genitalia – ulcers, urethral meatus for
edema and discharge.

17. investigations
Definative
Urinalysis - Urine specimens may be obtained by
midstream clean catch, suprapubic aspiration,
or catheterization
Dipstick testing - glucose, protein, blood, nitrite,
and leukocyte esterase
Leukocyte esterase 57-96% sensitive and 94-
98% specific for identifying pyuria

18. Nitrite tests are sensitivity and specificity of 22% and 94-100%, respectively.
Urine Culture – cystitis more than 1000 colony-forming units (CFU)/mL
Microscopic examination:
• Pyuria : Most truly infected patients have > 10 WBCs/μL. The presence of
bacteria in the absence of pyuria:due to contamination during sampling.
• Microscopic hematuria occurs in up to 50% of patients, but gross hematuria
is uncommon.
• WBC casts: pyelonephritis, glomerulonephritis, and noninfective
tubulointerstitial nephritis.
• Pyuria in the absence of bacteriuria and of UTI is possible, for example, if
patients have nephrolithiasis, a uroepithelial tumor, appendicitis, or
inflammatory bowel disease or if the sample is contaminated by vaginal
WBCs

19. • Complete blood count.
• HIV test
• VDRL
• Erythrocyte sedimentation rate

20. imaging
Ultrasonography
a. Abdominal - hydronephtosis pyonephrosis,
perirenal abcess.
b. Transrectal – prostatic abscess
c. Scrotal - acute scrotum
Ct scan of the abdomen.

21. treatment
Urethritis - gonococal ceftriaxone 250 mg IM plus
non gonoccocal azithromycin 1 g po once or
doxycycline 100 mg po bid for 7 days.
Cystitis
• First-line treatment of uncomplicated cystitis is
nitrofurantoin 100 mg po bid for 3 days (it is
contraindicated if creatinine clearance is < 60
mL/min),
• trimethoprim/sulfamethoxazole (TMP/SMX)
160/800 mg po bid for 3 days,

22. • Orchitis - scrotal support, cold compresses,
and bedrest
• Prostitis - fluroquinolones

23. prevention
• Practice of safe sex.
• Proper management of prevailing conditions.
• Proper care of urethral catheters.

24. UROLOGICAL OSTRUCTIONS
URETHRAL STRICTURES
Stricture; Circumscribed narrowing/stenosis of a viscus (hollow
structure) due to either scarring or deposition of abnormal tissue.
Therefore, Urethral Stricture defn:
-Diminution of the urethral caliber due to scarring of luminal
tissues or deposition of abnormal tissue in the lumen.
OR Narrowing of the lumen of the urethra causing functional
obstruction.
• A urethral stricture is a scar in or around the urethra, which can
block the flow of urine, and is a result of inflammation, injury or
infection

25. Classification & etiology
1. According to site:
a. Anterior urethra:
Bulbar: commonly post-gonorrheal, trauma,
instrumentation
Penile: Infections, Instrumentation
Glans meatus: Infections ,Instrumentation
b. Posterior urethra:
Bladder neck: Instrumentation, TURP, Cystitis,
Bladder Ca
Prostatic urethra: post-prostatectomy,
instrumentation
Membranous: trauma (e.g. pelvic fractures),
instrumentation
NB: Any part of urethra: follows
instrumentation.

26. 2.According to etiology:
a.Congenital (Rare) meatal
stenosis,congenital puv,
hypospadias epispadias
o Meatal stenosis assoc with
phimosis.
o Congenital posterior urethral
valves
o Hypospadias
o Epispadias

27. b. Acquired:
i) Inflammatory- post-gonorrheal,
shistosomiasis, TB,
urethral
chancre ( syphilis, H.ducreyi)
ii) Trauma - penetrating/blunt e.g.
pelvic fractures, saddle injury or penile
fracture
iii) Instrumental - indwelling
catheters of large caliber,
urethral endoscopy
iv) Post-operative- open
prostatectomy, TURP
amputation of the penis
V) Growths- giant warts, balanitis
xerotica obliterans
Vi) Neoplasm: Bladder
Transitional cell Ca.,
Penile shaft Squamous cell Ca
vi)Irradiation

28. Clinical presentation
• Pt. is usu. Young (< 40 yrs)
• Symptoms: Usu. Of BOO:
• 1.Complete stricture -- Acute retention
2. Incomplete stricture--Lower urinary tract
symptoms:
a) Voiding: Obstructive symptoms;
Progressive;
-hesitancy (worse in very full bladder)
-poor flow (improved by straining)
-intermittent stream-Dysuria
-sensation of poor bladder emptying; pt. tries
again (Pis-en-deux)
-episodes of near retention
-chronic retention with overflow
-post-micturitional dribbling
-perineal sinuses
-extravasation of urine

29. _b) Storage: Irritative symptoms;dysuria
-frequency -nocturia
-urgency -urge incontinence
-nocturnal incontinence (enuresis)
2. Other important Hx:
-STIs, Penile discharge, Haematuria -
Trauma -Instrumentation
-Surgery -Family hx of BPH or
Ca.Prostate
- Wasting -Bone Pain
-Anorexia -Symptoms of renal
failure
- Chronic d’ses e.g. DM, Parkinson’s,
Alzheimer’s

30. • Signs:
-Gen. Exam: Pallor, Signs or uraemia
-PA.: Palpable bladder, Palpable kidneys
-Local Exam: palpation of scarring
along line of urethra, fistula in perineum,
phimosis, paraphimosis, meatal stenosis,
observe the pt. micturating.
-DRE: R/O BPH or Ca. Prostate,
hemorrhoids
-difficulty in passing catheter

31. INVESTIGATIONS
• Urethroscopy-DVU (Direct Visual
urethrotomy)
• Urethrography: Retrograde
urethrography, Antegrade
cystourethrography (MCU)
• Ultrasound-
hydronephrosis,hydroureter
• Biopsy
• Urinalysis-hematuria
• Urine culture: to rule out UTI
• U/E/Cs
• Full hemogram;to rule out uti
• RBS to R/o DM as cause of urine
retention
• Cystoscopy if chronic retention

33. DDX
• BPH
• Ca. Prostate
• Ca. urethra
• Condyloma

34. MANAGEMENT
• Supportive:
-urine evacuation (-SPC in
acute retention or trauma, or
prolonged stricture)
-Analgesics-complicated by
urinary retention, UTI and stones
-Antibiotics

35. • Definitive:
1)Dilatation - Sounds, Filiforms &
Followers, Bougies, Guide wire,
Nelaton Catheters (Self-dilatation).
(2)Permanent stents
(3) Bypass - perineal urethrotomy
- suprapubic cystotomy
(4) Internal urethrotomy - visual/blind
(5) Urethroplasty

36. COMPLICATIONS
• Urine retention>UTI,calculi
• Ascending infection
• Urethral diverticulum
• Extravasation of urine
• Periurethral abscess
• Urethral fistula-2o to bursting or I & D of
abscess. If multiple, create a “watering-
can” perineum.
• Hernia, hemorrhoids (straining to void)
• Dilated uropathies (hydroureter,
hydronephrosis)
• extravasation of irrigation fluid into
perispongial tissues, thus increasing the
fibrotic response.

37. THANK YOU