الرحيم الرحمن الله الرحيم بسم الرحمن الله بسمUrologyUrology

Symptomatology & InvestigationsSymptomatology & Investigationsسعيد. هادي نعمان سعيد. د هادي نعمان د

الجراحة – فرع مساعد الجراحة – أستاذ فرع مساعد أستاذ M.B.Ch.B., M.R.C.S., Ph.D.(Uro), M.B.Ch.B., M.R.C.S., Ph.D.(Uro),

C.A.B.(Uro), F.J.M.C.(Uro) C.A.B.(Uro), F.J.M.C.(Uro)..

URINARY SYSTEMURINARY SYSTEMAnatomyAnatomyExtra peritoneal system, composed of Extra peritoneal system, composed of

two kidneys located in the upper two kidneys located in the upper abdomen protected by thoracic cage. abdomen protected by thoracic cage. - Each - Each weighs about 150 g.weighs about 150 g.Each kidney supplied by main renal Each kidney supplied by main renal artery from aorta, divided into 5 artery from aorta, divided into 5 segmental branches and drained by segmental branches and drained by renal vein to the inferior vena cava.renal vein to the inferior vena cava.

Collecting systemCollecting system

Composed of Composed of 33 major calyces, each drains major calyces, each drains 3-5 3-5 minor calyces, joins together to form minor calyces, joins together to form renal pelvis which is connected to the bladder renal pelvis which is connected to the bladder by muscular tube called the ureter.by muscular tube called the ureter.

LEFT RENAL ANATOMYLEFT RENAL ANATOMY

Kidneys relation to the skeletonKidneys relation to the skeleton

URINARY BLADDER RELATIONS IN URINARY BLADDER RELATIONS IN BOTH SEXESBOTH SEXES

The three common sites of stone impaction in the ureters ( normal narrowing) are :

Pelviureteric junction Pelviureteric junction (PUJ)(PUJ)

Where the ureters Where the ureters cross the iliac vesselscross the iliac vessels

Ureterovesical Ureterovesical junction (UVJ) which junction (UVJ) which is the narrowest partis the narrowest part

FUNCTIONSFUNCTIONS

1-1- Excretion of metabolic end products. Excretion of metabolic end products.2- 2- Control body fluid constituents Control body fluid constituents concentration.concentration.3-3- Control acid base balance. Control acid base balance.4- 4- Hormone and enzymeHormone and enzyme

SymptomatologySymptomatologyThe basic approach to the patient in urology is The basic approach to the patient in urology is still dependent on taking a completestill dependent on taking a complete HistoryHistory, , executing a thoroughexecuting a thorough PhysicalPhysical ExaminationExamination, , and performing aand performing a UrinalysisUrinalysis..

HISTORYHISTORY A complete history can be divided into three major A complete history can be divided into three major componentscomponents:: - The chief complaint - The chief complaint - History of the present illness - History of the present illness - Past history - Past history..

PainRenal Pain:Pain is usually caused by Pain is usually caused by acute distentionacute distention of the of the

renal capsule, generally from inflammation, or renal capsule, generally from inflammation, or obstructionobstruction of minor calyx or PUJ by a stone of minor calyx or PUJ by a stone..

- - Pain due to inflammation is usually steadyPain due to inflammation is usually steady Dull aching at the Dull aching at the renal angle radiate to the relevant hypochondrium usually renal angle radiate to the relevant hypochondrium usually associated with fever and general ill health.associated with fever and general ill health.

Eg.: Pyelonephritis, pyonephrosis, and renal abscess.Eg.: Pyelonephritis, pyonephrosis, and renal abscess.

- - Pain due to obstruction is colicky &fluctuates in Pain due to obstruction is colicky &fluctuates in intensityintensity..

Pain of renal origin may be associated with gastrointestinal Pain of renal origin may be associated with gastrointestinal symptoms like nausea & vomiting.symptoms like nausea & vomiting.

Ureteral Pain (Ureteral Pain (Ureteric Colic):Ureteric Colic):

Sudden severe agonizing pain, started at the loin, radiates Sudden severe agonizing pain, started at the loin, radiates to the ipsilateral iliac fossa, suprapubic region,to the ipsilateral iliac fossa, suprapubic region, and genitalia and genitalia Associated with nausea, vomiting, and urinary symptoms Associated with nausea, vomiting, and urinary symptoms like hematuria or dysuria. like hematuria or dysuria. The patient is rolling around. The patient is rolling around. ((Contrast this with theContrast this with the

patient suffering from peritoneal pain, who lies still to avoid exacerbating patient suffering from peritoneal pain, who lies still to avoid exacerbating the pain by movement.the pain by movement. ) )It is ischemic painIt is ischemic painUsually due to acute ureteral obstruction either by Usually due to acute ureteral obstruction either by stone, stone, clot, crystals, sloughed tissue or papillaeclot, crystals, sloughed tissue or papillae.. The site of ureteral obstruction can often be determined by the The site of ureteral obstruction can often be determined by the location of the referred pain.location of the referred pain. If the cause in the lower ureter the pain If the cause in the lower ureter the pain radiates to the testicle, labia or inner aspect of the thigh.radiates to the testicle, labia or inner aspect of the thigh.

Vesical Pain: Vesical Pain: Suprapubic pain aggravated by Suprapubic pain aggravated by

vesical filling, relieved by urination.vesical filling, relieved by urination. Produced either byProduced either by

overdistentionoverdistention of the bladder as a result of acute of the bladder as a result of acute urinary retention urinary retention or by or by Bladder Bladder inflammationinflammation (cystitis) (cystitis)

Prostatic painProstatic pain : : Usually secondary to inflammation Usually secondary to inflammation

((Prostatitis)Prostatitis) with secondary edema and with secondary edema and distention of the prostatic capsule.distention of the prostatic capsule.

Usually felt deep in the rectum, penis, pelvis Usually felt deep in the rectum, penis, pelvis perineum, suprapubic, low backache, & both perineum, suprapubic, low backache, & both iliac fossae.iliac fossae.

Urethral pain:Urethral pain:

Scalding in nature usually at the tip of the penis Scalding in nature usually at the tip of the penis but sometimes at its base, usually due to but sometimes at its base, usually due to urethritis, cystitis or vesical or urethral calculus.urethritis, cystitis or vesical or urethral calculus.

N.B.: TumorsN.B.: Tumors in the GU tract usually do not in the GU tract usually do not cause pain unless they produce obstruction or cause pain unless they produce obstruction or extend beyond the primary organ to involve extend beyond the primary organ to involve adjacent nerves.adjacent nerves.

Testicular PainTesticular Pain : :

Primary pain arises from within the scrotum and Primary pain arises from within the scrotum and most commonly secondary to acute most commonly secondary to acute epididymo epididymo orchitis or torsionorchitis or torsion of the testicle or testicular of the testicle or testicular appendices or appendices or traumatrauma..

Because the testicles arise embryologically in close Because the testicles arise embryologically in close proximity to the kidneys, pain arising in the kidneys proximity to the kidneys, pain arising in the kidneys or retroperitoneum may be referred to the testicles.or retroperitoneum may be referred to the testicles. Similarly, the dull pain associated with an inguinal hernia Similarly, the dull pain associated with an inguinal hernia may be referred to the scrotum.may be referred to the scrotum.

Also testicular pain may by referred to the epigastric region.Also testicular pain may by referred to the epigastric region.

HematuriaHematuria

The presence of blood in the urine.The presence of blood in the urine. >> 3 3 RBC /HPF is significant. RBC /HPF is significant.

Hematuria of any degree should never be Hematuria of any degree should never be ignored and, in adults, should be ignored and, in adults, should be regarded as regarded as a feature of urologic malignancy until proved a feature of urologic malignancy until proved otherwise.otherwise.

The most common cause of gross hematuria The most common cause of gross hematuria in a patient older than age in a patient older than age 5050 years is years is bladder cancer.bladder cancer.

Important points about hematuriaImportant points about hematuria

- - Macroscopical or microscopicalMacroscopical or microscopical? ? - - Initial, terminal or totalInitial, terminal or total? ? - - Painless or painful.Painless or painful.? ?

- - Intermittent or persistentIntermittent or persistent??- - If the patient is passing clots, do the clots If the patient is passing clots, do the clots have a specific shape ( thread like + ureteric or have a specific shape ( thread like + ureteric or renal origion)renal origion)??

Causes:Causes:- Local cause like stone, UTI, trauma, or malignancy.- Local cause like stone, UTI, trauma, or malignancy.- Systemic cause like bleeding tendency- Systemic cause like bleeding tendency

If there is a malignant cause for the haematuria If there is a malignant cause for the haematuria there is usually no painthere is usually no pain..

Blood appearing at the beginning of the urinary stream indicates a lower urinary tract cause. uniform staining throughout the stream points to a cause higher up. Terminal haematuria is typical of severe bladder irritation caused stone or infection.

Lower Urinary Tract SymptomsLower Urinary Tract Symptoms Irritative SymptomsIrritative SymptomsFrequencyFrequency : : Increase in the number or times of urination. Increase in the number or times of urination.

The normal bladder capacity is about The normal bladder capacity is about 400-500mL400-500mLThe normal adult voids The normal adult voids 5-6 times5-6 times per day, with a per day, with a volume of approximately volume of approximately 300mL300mL with each void. with each void. Urinary frequency is due Urinary frequency is due either to increased urinary output (polyuria) or to either to increased urinary output (polyuria) or to decreased bladder capacity.decreased bladder capacity.

Causes:Causes: SystemicSystemic: compulsive water drinking, DM, DI or diuretics : compulsive water drinking, DM, DI or diuretics use.use.LocalLocal: stone, infection, BPH or prostatic carcinoma. : stone, infection, BPH or prostatic carcinoma.

Nocturia:Nocturia: nocturnal frequency nocturnal frequency

Dysuria:Dysuria: painful urination (burning painful urination (burning sensation) that is usually caused by sensation) that is usually caused by inflammationinflammation

UrgencyUrgency : sudden strong desire to urinate : sudden strong desire to urinate that the patient cannot postpone itthat the patient cannot postpone it

Obstructive SymptomsObstructive Symptoms Weak streamWeak stream decreased force (flow) of urination. decreased force (flow) of urination.Urinary Urinary HesitancyHesitancy a delay in the starting a delay in the starting (initiation) of micturition(initiation) of micturition IntermittencyIntermittency involuntary start-stopping of the involuntary start-stopping of the urinary stream (interrupted urinary stream). urinary stream (interrupted urinary stream). Postvoid dribblingPostvoid dribbling the terminal release of the terminal release of drops of urine at the end of micturitiondrops of urine at the end of micturitionStrainingStraining use of abdominal musculature to use of abdominal musculature to urinate.urinate.Feeling of Feeling of Incomplete bladder evacuation.Incomplete bladder evacuation.

Retention of urine: Inability to pass urine in spite of a Retention of urine: Inability to pass urine in spite of a full bladder ( due to outlet obstruction)full bladder ( due to outlet obstruction)..

Acute & chronic

N.B.:Anuria: complete absence of urine Anuria: complete absence of urine production.production.Oliguria is present when less than 300 ml Oliguria is present when less than 300 ml of urine is excreted in a dayof urine is excreted in a day

IncontinenceIncontinenceInvoluntary loss of urineInvoluntary loss of urine or or Inability to control urination.Inability to control urination.

1.1. Continuous incontinenceContinuous incontinence. . 2.2. Stress incontinenceStress incontinence. . 3.3. Urgency incontinenceUrgency incontinence. . 4.4. Overflow urinary incontinenceOverflow urinary incontinence

Nocturnal EnuresisNocturnal Enuresis : Bed wetting (urinary incontinence : Bed wetting (urinary incontinence that occurs during sleep ) that occurs during sleep ) Physiological during first Physiological during first 2-3 yr of age2-3 yr of age

Urethral DischargeUrethral Discharge

Pyuria: Pyuria: presence of pus in the urine.presence of pus in the urine.

Chyluria: Chyluria: presence of lymph in the urine.presence of lymph in the urine.Phosphaturia: Phosphaturia: presence of phosphate crystalspresence of phosphate crystals in the urine.in the urine.Necroturia: Necroturia: presence of necrotic tissue in the presence of necrotic tissue in the urine as in malignancy.urine as in malignancy.Pneumaturia: Pneumaturia: presence of air in the urine.presence of air in the urine.

Past HistoryPast History

Past Medical HistoryPast Medical History PastPast Surgical Surgical HistoryHistory Family HistoryFamily History Smoking and Alcohol UseSmoking and Alcohol Use AllergiesAllergies

PHYSICAL EXAMINATIONPHYSICAL EXAMINATIONWith the exception of:With the exception of:• renal and scrotal masses or tenderness. renal and scrotal masses or tenderness. • palpable bladder palpable bladder • abnormal prostate on digital rectal examination.abnormal prostate on digital rectal examination. urological conditions are most likely to be urological conditions are most likely to be

diagnosed from the history or by investigations.diagnosed from the history or by investigations.

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

General ObservationsGeneral Observations Bimanual examination ofBimanual examination of t the kidney he kidney

The kidney is lifted from behind with one The kidney is lifted from behind with one hand in the costovertebral angle & palpated with thand in the costovertebral angle & palpated with t

the other handthe other hand In children and thin women, it may be possible In children and thin women, it may be possible

to palpate the lower pole of the right kidney to palpate the lower pole of the right kidney

with deep inspiration.with deep inspiration. Exam. of the Renal angleExam. of the Renal angle

Bladder examination:Bladder examination:

A normal bladder in the adult cannot be palpated or percussed A normal bladder in the adult cannot be palpated or percussed

until there is at least until there is at least 150 mL150 mL of urine in it. of urine in it. Percussion is better than palpation for diagnosing a distended Percussion is better than palpation for diagnosing a distended

bladder.bladder.

Scrotal examinationScrotal examinationA firm or hard painless mass within the testis should be A firm or hard painless mass within the testis should be

considered a considered a malignantmalignant tumor until proved otherwise. tumor until proved otherwise. Transillumination is helpful in diagnosing hydrocele.Transillumination is helpful in diagnosing hydrocele.

Prostate Examination:Prostate Examination: Digital rectal examination (DRE) should be performed in every male after Digital rectal examination (DRE) should be performed in every male after

age age 4040 yearsyears and in men of any age who present for urologic and in men of any age who present for urologic evaluation.evaluation.

Normally, the prostate is about the size of a chestnut and has a firm Normally, the prostate is about the size of a chestnut and has a firm consistency similar to that of the contracted thenar eminence of the consistency similar to that of the contracted thenar eminence of the thumbthumb..

Pelvic Examination in the FemalePelvic Examination in the Female

InvestigationsInvestigationsI- I- URINALYSIS URINALYSIS ((General urine examination: GUE)General urine examination: GUE) complete urinalysis includes complete urinalysis includes physicalphysical,, chemical, and microscopic chemical, and microscopic

analyses. analyses. Physical: color, pH, & Physical: color, pH, & Specific GravitySpecific GravityColorColor : yellowish : yellowishTurbidityTurbidity :phosphaturia , Pyuria :phosphaturia , Pyuria Specific Gravity and OsmolalitySpecific Gravity and Osmolality : : Specific GravitySpecific Gravity usually varies from usually varies from 1.003 to 1.030.1.003 to 1.030. Osmolality is a measure of the amount of material dissolved in the urine Osmolality is a measure of the amount of material dissolved in the urine

and usually varies between and usually varies between 50 and 1200 mOsm/L50 and 1200 mOsm/L..

pHpH the average pH varies between the average pH varies between 5.5 and 6.55.5 and 6.5 Biochemical Examination of UrineBiochemical Examination of Urine The abnormal substances commonly tested for with a dipstick include The abnormal substances commonly tested for with a dipstick include

(1) (1) HemoglobinHemoglobin, (2) , (2) proteinprotein, (3) , (3) glucoseglucose, (4) , (4) ketonesketones, (5) , (5) ElectrolytesElectrolytes, , (6) (6) myoglobinmyoglobin , , and (7) and (7) urobilinogen and bilirubinurobilinogen and bilirubin..

Microscopic analysesMicroscopic analysesCellsCells (RBC , Leukocytes , Epithelial cells , Renal (RBC , Leukocytes , Epithelial cells , Renal tubular cells) tubular cells) Casts Casts :: cast is a protein coagulum that is formed cast is a protein coagulum that is formed in the renal tubule in the renal tubule (The presence of protein casts suggests disease affecting the renal parenchyma)

Crystal Crystal

BacteriaBacteria

Five Five bacteria/HPF reflects colony counts of about bacteria/HPF reflects colony counts of about 100,000 bacteria/mL100,000 bacteria/mL

The finding of The finding of any bacteriaany bacteria in a properly collected in a properly collected midstream specimen from a male should be midstream specimen from a male should be further evaluated with a further evaluated with a urine cultureurine culture

Mid stream urine for c&s. Mid stream urine for c&s. Early morning sample for AFBEarly morning sample for AFB

Cytology: Cytology: poorly differentiated transitional cell tumours poorly differentiated transitional cell tumours anywhere in the urinary tractanywhere in the urinary tract..YeastYeast ParasitesParasites : Schistosoma ovum : Schistosoma ovum

Bacteriological cultureBacteriological culture

Culture & sensetivity (C&S) Culture & sensetivity (C&S) of a clean-catch of a clean-catch midstream specimenmidstream specimen

If there are pus cells in the urine but thereIf there are pus cells in the urine but there is no growth on the routine culture media (sterile pyuria), it is worth testing for more fastidious organisms.

- Multiple early-morning urine specimens must be cultured on Multiple early-morning urine specimens must be cultured on L0wenstein–Jensen medium to detect urinary tract tuberculosis.L0wenstein–Jensen medium to detect urinary tract tuberculosis.

- ChlamydiaChlamydia

Analysis of a 24-hour specimen of urineAnalysis of a 24-hour specimen of urine

Quantify the rate of loss, and is especially useful in the investigation of calculus disease caused by

abnormal excretion of calcium, oxalate, uric acid and other products of metabolism

II- II- Renal function tests:Renal function tests:

More than More than 70%70% of kidney function must be lost of kidney function must be lost before renal failure becomes evident (before renal failure becomes evident (Because Because of large renal reserve, considerable structural of large renal reserve, considerable structural damage can occur before functional damage damage can occur before functional damage become apparent).become apparent).

1- 1- Blood urea (Blood urea (Blood Urea Nitrogen)Blood Urea Nitrogen)normally normally (15-40 mg/dl) (15-40 mg/dl) (2.5-6.5 mmol/l) (2.5-6.5 mmol/l)

It increases in dehydration, fasting, fever & after It increases in dehydration, fasting, fever & after

protein meal. Also in renal failureprotein meal. Also in renal failure

2- 2- Serum creatinineSerum creatinine:: (0.6-1.2 mg/dl)(0.6-1.2 mg/dl) ( 62-124 ( 62-124 µµmol/l)mol/l)

More accurate than urea and less affected by More accurate than urea and less affected by dehydration.dehydration.

3- 3- Creatinine clearanceCreatinine clearance:: (85-120 ml/min)(85-120 ml/min)Creatinine clearance test will give an approximate Creatinine clearance test will give an approximate

value for glomerular filtration ratevalue for glomerular filtration rate Needs Needs 24h urine collection and a sample of blood. Cr. 24h urine collection and a sample of blood. Cr. CL.=UV/PCL.=UV/P

U : Cr. in urine (mg/dl)U : Cr. in urine (mg/dl) V: ml of urine excreted (per minute or 24hour)V: ml of urine excreted (per minute or 24hour) P: Cr. in plasma (mg/dl)P: Cr. in plasma (mg/dl)

III- III- Tubular function tests:Tubular function tests:

1- Specific gravity: (1.003-1.030).1- Specific gravity: (1.003-1.030).2- Ion excretion test: Na2- Ion excretion test: Na++ β2-β2-microglobulinmicroglobulin

URINARY TRACT IMAGINGURINARY TRACT IMAGING

ULTRASONOGRAPHY (ULTRASONOGRAPHY (U/SU/S )) Structural study to differentiate cystic or solid

masses, hydronephrosis, renal size, renal cortical thickness, and stones.

The volume of urine in the bladder before and after micturition can be calculated, and even tiny filling defects within it detected.

The prostate Scrotal contents can be displayed in great detail.Scrotal contents can be displayed in great detail. TRUS (transrectal U/S):TRUS (transrectal U/S): for prostate evaluation and for prostate evaluation and

U/S guided prostate biopsyU/S guided prostate biopsy..

U/S is Non invasive, available, cheap, painless, fast, portable, U/S is Non invasive, available, cheap, painless, fast, portable,

and almost no contraindicationsand almost no contraindicationsA brief pulse of high-frequency sound energy produced by a A brief pulse of high-frequency sound energy produced by a

transducer is transmitted into the patient. The sound waves transducer is transmitted into the patient. The sound waves interact with the tissue and are either interact with the tissue and are either reflected, refracted, or reflected, refracted, or absorbedabsorbed, depending on the type of tissue involved, depending on the type of tissue involved

A calculus in the kidney casts an A calculus in the kidney casts an acoustic shadowacoustic shadow

X-Ray: KUBX-Ray: KUB (kidneys, ureters, bladder) (kidneys, ureters, bladder)

A plain radiograph of the abdomen and pelvis A plain radiograph of the abdomen and pelvis includes the area above both adrenal glands includes the area above both adrenal glands (lower chest) and extends to 2 cm below the (lower chest) and extends to 2 cm below the symphysis pubis(includes the external genitalia)symphysis pubis(includes the external genitalia)

ssite, ite, ssex, ex, sstones, ptones, pssoas shadow, oas shadow, sskeleton, and keleton, and ssoft oft tissue shadow.tissue shadow.

IndicationsIndications

1)1) as a primary study as a primary study 2)2) as a scout film before contrast material injection as a scout film before contrast material injection

EXCRETORY UROGRAPHY (IVU , IVP, EXU )EXCRETORY UROGRAPHY (IVU , IVP, EXU )

These are organic chemicals to which These are organic chemicals to which iodine atomsiodine atoms are areattached to absorb X-rays.attached to absorb X-rays.Allows visualization of the entire urinary tract. The study Allows visualization of the entire urinary tract. The study

provides demarcation of the renal parenchyma, the provides demarcation of the renal parenchyma, the pelvicalyceal system, ureters, and bladder, providing pelvicalyceal system, ureters, and bladder, providing both both anatomic and functionalanatomic and functional information. information.

Number, size, site, function of the kidneys, anatomy of the Number, size, site, function of the kidneys, anatomy of the collecting system, hydronephrosis, and filling defects, collecting system, hydronephrosis, and filling defects, stones.stones.

The hypertonicity of the contrast media may have ill effects The hypertonicity of the contrast media may have ill effects on the cardiovascular system, the coagulation cascade, on the cardiovascular system, the coagulation cascade, the blood-brain barrier, and the kidneys.the blood-brain barrier, and the kidneys.

Adverse Effects of Contrast MediaAdverse Effects of Contrast Media

- - Idiopathic or anaphylactoid reactionsIdiopathic or anaphylactoid reactions - Contrast media may induce an acute impairment of - Contrast media may induce an acute impairment of

renal functionrenal function- Diabetics managed with metformin (Glucophage)- Diabetics managed with metformin (Glucophage) should have the drug withheld for 48 hours after should have the drug withheld for 48 hours after

receiving contrast material.receiving contrast material.

C.I.:C.I.: allergy, pregnancy, and renal impairment allergy, pregnancy, and renal impairment

Patient PreparationPatient Preparation

RETROGRADE PYELOGRAPHYRETROGRADE PYELOGRAPHY Opacification of the ureter and pelvicalyceal system by the Opacification of the ureter and pelvicalyceal system by the

retrograde injection of contrast media using ureteric catheter.retrograde injection of contrast media using ureteric catheter.

IndicationsIndications Employed after an excretory Employed after an excretory urogram that inadequately urogram that inadequately visualized the anatomy of visualized the anatomy of the upper tract. the upper tract.

when there are when there are contraindications to do IVUcontraindications to do IVU

Retrograde ureterogram demonstrating the collectingsystem. The radiolucent filling defect in the renal pelvis is caused by a uric acid calculus.caused by a uric acid calculus.

CYSTOURETHROGRAPHYCYSTOURETHROGRAPHY Contrast-enhanced imaging of the lower urinary tract provides Contrast-enhanced imaging of the lower urinary tract provides

valuable information on the function and anatomy of the bladder valuable information on the function and anatomy of the bladder and urethra and urethra

Voiding ( micturating) Cystourethrography (MCUG): looking for vesicoreteric reflux

COMPUTED TOMOGRAPHY ( CT scan)COMPUTED TOMOGRAPHY ( CT scan)

Non ContrastedNon Contrasted (Native, non enhanced) (Native, non enhanced)ContrastedContrasted: Oral Contrast Agents: Oral Contrast Agents Intravenous Contrast AgentsIntravenous Contrast Agents

CT scan accurately characterize the nature of tissue in the lesion. CT is useful in the preoperative evaluation and staging of tumors. CT has replaced IV urography as the primary modality for the assessment of suspected renal injuries and their complications For the evaluation of patients with acute flank pain, unenhanced spiral CT is more sensitive in detecting calculi than EXU. (except indinaver no radiolucent stones).

Drawbacks: Expensive, more radiation, not always available, need experience, contrast contraindications, pregnancy

MAGNETIC RESONANCE IMAGINGMAGNETIC RESONANCE IMAGING (MRI) (MRI)Protons within the body can be thought of as small, spinning bar Protons within the body can be thought of as small, spinning bar

magnets. Hydrogen has a single proton. When a patient is magnets. Hydrogen has a single proton. When a patient is placed in a large magnetic field, the hydrogen protons within placed in a large magnetic field, the hydrogen protons within the body align, and this alignment leads to the formation of a the body align, and this alignment leads to the formation of a net magnetic vector within the patient. net magnetic vector within the patient.

ContrastContrast: Gadolinium: Gadolinium No radiationNo radiation

NUCLEAR IMAGINGNUCLEAR IMAGING

The radionuclides currently available can measure The radionuclides currently available can measure perfusion,perfusion, functional morphologyfunctional morphology (glomerular filtration and tubular (glomerular filtration and tubular secretion),secretion), excretion excretion, and , and cortical morphologycortical morphology..

Technetium Tc 99m Diethylenetriaminepenta-acetic AcidTechnetium Tc 99m Diethylenetriaminepenta-acetic Acid 99mTc-99mTc-DTPA DTPA Technetium Tc 99m MercaptoacetyltriglycineTechnetium Tc 99m Mercaptoacetyltriglycine 99mTc- 99mTc-MAG3 MAG3

Technetium Tc 99m Dimercaptosuccinic AcidTechnetium Tc 99m Dimercaptosuccinic Acid 99mTc- 99mTc-DMSADMSA

It gives the split function of each kidneyIt gives the split function of each kidney

ANGIOGRAPHYANGIOGRAPHY Currently, CT, MRI, and ultrasonography have supplanted Currently, CT, MRI, and ultrasonography have supplanted

angiography for most diagnostic indications, providing angiography for most diagnostic indications, providing equivalent and at times greater information with markedly equivalent and at times greater information with markedly decreased morbidity and risk.decreased morbidity and risk.

Endoscopy:Endoscopy:

Direct visualization of Direct visualization of the internal parts of the internal parts of the organ. the organ. Urethroscope, Urethroscope, Cystoscope, Cystoscope, Ureteroscope Ureteroscope and Renoscope.and Renoscope.

Urodynamic studies:Urodynamic studies:

To study the function of the lower urinary To study the function of the lower urinary tract( vesico-urethral unit). tract( vesico-urethral unit).

Include Include cystometry, flow rate, urethral cystometry, flow rate, urethral pressure profile, video urodynamic pressure profile, video urodynamic studies, and EMG of pelvic floorstudies, and EMG of pelvic floor..

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