All posts by World Endourology Training Institute


Urethral strictures have plagued men since antiquity, with etiologic evolution reflecting changes in population distribution, human diseases, occupational hazards, and environmental factors [1]. African urologists have contributed substantially to the advance in techniques of urethroplasty, notably Quartey [2] who sought to reconstruct long bulbar urethral strictures due to gonococcal urethritis, and El-Kasaby [3], a pioneer in the use of buccal mucosa for anterior urethroplasty. Bulbar urethral strictures, due to anatomical and etiological differences from strictures in the penile urethra, can be treated effectively with very high success rates. In this location, stricture outcomes are less impacted by variables such as prior irradiation; comorbid medical conditions; deficiencies in genital skin; or lichen sclerosus. However, due the greater ease and safety of endoscopic procedures, many patients undergo innumerable dilations or internal urethotomies, even when success is unlikely.The long-term consequence of this practice pattern will be to increase the length of strictures, rendering some unsuitable for primary anastomotic repair and instead requiring substitution procedures such as oral graft urethroplasty.

Contemporary urethral stricture disease in the United States most commonly is caused by idiopathic and traumatic causes. Although accurate statistics have not been determined for African men, traumatic bulbar urethral strictures are postulated to predominate, reflecting the burden of motor vehicle, pedestrian, and other transport injuries, and war, on young men across the continent. The Global Burden of Disease Study 2013 ranks these as major sources of disability worldwide, with a greater burden in developing countries. In contrast, iatrogenic and idiopathic causes will increase in prevalence in parallel with the increasing frequency of urological interventions in the aging male across the world. This paper reviews the diagnostic concerns, technique, and outcomes of substitution urethroplasty using ventrally placed oral mucosa and speculates on the future of urethroplasty.

Preoperative evaluation

Cystoscopy is a simple way to confirm the presence of suspected urethral stricture disease. However, it has limited value in preoperative planning because it cannot determine the length of the stricture or the status of the more proximal urethra. This is of particular importance to the current discussion, because ventral onlay approach allows easy extension of the substitution “onlay” or “patch graft” into the most proximal portions of the anterior urethra.

The combination of retrograde urethrogram and voiding cystourethrogram accurately assesses the bulbar urethra and determination of the length of a stricture along with its functional significance. Techniques for retrograde and voiding urethography have been reviewed elsewhere. However, one point requires elaboration related to bulbar urethral stricture: the penis must be adequately stretched so that the pendulous portion of the penile urethra and the penoscrotal junction are appropriately visualized

Ultrasonography [8] provides a very accurate delineation of a bulbar urethral stricture and may be valuable in assessing the luminal diameter of the stricture, which determines strategies for addressing very narrow portions of a longer stricture

Reconstructive considerations

Antegrade and retrograde blood supply of the corpus spongiosum is key to successful bulbar urethroplasty because it affords the reconstructive surgeon the ability to mobilize, excise and reanastomose the urethral plate in combination with free graft tissue transfer. However, many strictures exceed the limits of urethral mobilization and primary anastomosis, leading to the innovations in substitution urethroplasty. No controlled clinical study has definitively shown superiority of oral mucosa to full thickness genital skin, and odds of recurrence are similar to earlier series using penile skin. Nevertheless, ease of harvesting and lack of donor site morbidity have led to widespread adoption of oral mucosa for substitution urethroplasty.

A brief algorithm for the treatment for urethra Strictures greater than 2 cm in length in the bulbar urethra generally require substitution urethroplasty with a free graft, although longer gaps can be bridged depending on the elasticity of the corpus spongiosum and location of the stricture. Systematic review suggests that dorsal grafting offers equal success rates compared to ventral; in our hands the rates of success were not statistically different (85% vs. 81%). An earlier single institution series suggested equal outcomes for penile skin versus buccal mucosa, but more recent systematic review suggests inferior outcomes for penile skin; few centers can achieve success rates above 90% with long term follow up. The higher rate of success of dorsal onlay determined in some case series may reflect lead time bias in the earlier literature, because ventral onlay techniques have been disseminated for a longer time interval than dorsal.

When a segment of a bulbar urethral stricture is obliterated or nearly obliterated the reconstruction must address the narrowest portion, either by excision of the most severe portion of the stricture, with dorsal reanastomosis and ventral onlay reconstruction (augmented anastomotic urethroplasty) or using a strategy advanced by Barbagli and associates [19] in which a portion of the spongiosum is not covered with the graft and allowed to heal by secondary intention. This latter conceptual advance may reduce the need to perform augmented anastomotic procedures.

Surgical technique

Patients undergoing bulbar urethroplasty require the lithotomy position. An experienced member of the surgical team should position the legs to minimize potential compression of the peroneal nerve or excessive flexion of the knee. Risk of lower extremity complications is influenced by use of Trendelenberg, knee position, external compression, method of leg support, duration of surgery, and patient factors including age and body mass.

The technique of oral mucosa harvesting is covered elsewhere in this edition and for the sake of brevity will not be repeated. Optimal graft take depends on imbibition of nutrients and thus all fat and muscle are removed from the undersurface of the graft.

Ventral onlay free graft substitution takes advantage of outstanding visualization of the proximal-most bulbar urethra and the excellent vascularity of the recipient site. Exposure of the corpus spongiosum requires that the surgeon either split the overlying bulbospongiosus muscle in the midline, or follow the more contemporary vogue of mobilization and retraction of the muscle. Extensive mobilization of the corpus spongiosum is not required with ventral onlay, and its vascular supply from perforators originating in the corpus cavernosum should not be sacrificed.

The distal extent of the stricture is marked using a 20 Fr. catheter, placed per urethra until resistance is met. Barbagli and Kulkari suggest that ventral onlay is ideal for strictures in which the distal-most extent of the stricture is proximal to the distal margin of the bulbospongiosus muscle. The implication is that the stricture extends closer to the external sphincter proximally, in which case ventral approach allows superb visualization and precise suturing of the onlay graft as far proximal as the veru montanum.

A ventral urethrotomy must be made through the entire length of the stricture, extending into healthy urethral epithelium and spongy tissue . By placing stay sutures though the ventral surface of the corpus spongiosum, at the level of the catheter tip, the corpus spongiosum is incised in the ventral midline with a scalpel until the catheter is exposed. The urethrotomy is then extended proximally, placing additional full thickness stay sutures at close intervals for hemostasis and to aid subsequent identification of the mucosal for anastomosis. The urethrotomy is extended until the entire stricture has been incised.

Proximal and distal calibration of the urethra should confirm a minimal urethral lumen of 28 Fr. The apex of graft is anastomosed to the proximal apex of the urethrotomy with a series of interrupted sutures; running 5-zero absorbable suture then completes the anastomosis along each side of the graft. The distal graft is then trimmed to size and approximated to the distal apex with interrupted sutures. The apical lumen is calibrated and a 16 Fr Foley catheter inserted before or after completion of graft suturing. Next, to support the graft and allow appropriate take, the corpus spongiosum is closed with interrupted 4–0 absorbable sutures.

If a portion of the stricture is extremely fibrotic or narrow, the underlying graft bed may be poor or the spongiosum may not adequately cover the graft. In such cases excision of that portion of the stricture, followed by dorsal reanastomosis, should be performed in conjunction with grafting.

To finish the closure, the bulbospongiosus muscle, Colles’ fascia, and skin are all closed with interrupted or running absorbable sutures. Drains are rarely required with ventral onlay because the spongiosal closure is very hemostatic.

Postoperative care and follow up

Patients undergoing bulbar urethroplasty can be discharged in less than 24 h. Routine catheter care and limited physical activity are observed until a voiding cystourethrogram or pericatheter retrograde urethrogram is performed at week 2. If contrast extravasation persists, the cathter is replaced and a repeat study is completed in 1–2 weeks. If the amount of extravasation is minor, voiding is allowed or catheter drainage is reinstituted for one more week without repeat imaging. Patients refrain from sexual activity for 4 weeks. Perineal precautions limit pressure on the repair and prohibit bicycle riding for 3 months.


Patient characteristics

We previously reported our combined outcomes of dorsal and ventral onlay bulbar urethroplasty [16]; the current analysis is restricted to the subset of patients who underwent ventral onlay. Mean age of these 62 patients was 40 years, and strictures had undergone prior intevention in 87%. Stricture length averaged 3.9 cm, indicating the need for substitution urethroplasty. The other demographic features were not relevant to technique or outcomes. Intraoperative bleeding is modestly high with ventral onlay, but none of the 62 required transfusion (data not shown).


Minor surgical complications include incisional bleeding, hematuria, and diverticulum formation, occurred in less than 5% of patients after substitution urethroplasty . Complications of the lithotomy position can include peroneal neuropraxia, back pain, and rare compartmental syndrome of the calf. None occurred in the current sample. Other complications of urethroplasty include infection, fistula formation, sexual dysfunction and stricture recurrence (.

Donor site complications include contraction, pain or minor difficulties with food or saliva. Sexual dysfunction occurs after urethroplasty and therefore baseline assessment of function is advisable. Approximately 40% of men experience a degree of erectile dysfunction after urethroplasty, although the majority return to baseline within 1 year. Orgasmic dysfunction, in particular abnormal ejaculation, is prevalent in men with urethral stricture disease, and is likely to improve postoperatively.

Outcomes and follow up

No consensus method of follow up after urethroplasty has been consistently adopted worldwide [28]. We assess outcomes with uroflowmetry and cystoscopy at 3 and 12 months, and then expectantly after the first year. Our rate of stricture recurrence after ventral onlay, defined by need for repeat intervention for the stricture, with a mean follow up of 38 months was 19%. Time to recurrence was up to 5 years after surgery. The majority of recurrent strictures occur at either the proximal or distal end of the graft. These create ring-like narrowing that spares the majority of the graft, and require DVIU. Approximately 5% of patients required repeat urethroplasty, which may be by anastomotic techniques if isolated to one end of the grafted urethra, or by repeat substitution using a dorsal oral mucosa graft onlay approach or a ventral skin flap urethroplasty. With a small sample size, analysis of variables that predict failure is limited.
Table 1.

Ventral onlay (N = 62)
Demographic characteristics
Age, yrs (SD) 40.1 (13.3)
BMI, kg/m2 (SD) 30.2 (7.3)
Diabetes, N (%) 5 (8%)
Current smoker, N (%) 7 (11%)
Stricture characteristics
Etiology, N (%)
Trauma/Instrumentation 25 (40%)
Lichen sclerosis/infection 5 (8%)
Hypospadias 2 (3%)
Radiation 3 (5%)
Unknown 27 (43%)
Prior procedure, N (%) 54 (87%)
Prior DVIU, N (%) 44 (71%)
Prior dilation, N (%) 33 (53%)
Prior urethroplasty, N (%) 5 (8%)
Prior stent, N (%) 4 (6%)
Surgical characteristics
Stricture length, cm (SD) 3.9 (1.17)
Graft size, cm2 (SD) 9.5 (1.91)
Augmented anastomosis, N (%) 9 (15%)
Surgical complications
Mean follow-up, months 38.2 (34.6)
Incisional bleeding, N (%) 1 (1.6%)
Hematuria, N (%) 1 (1.6%)
Diverticulum, N (%) 3 (5%)
Failure, N (%) 12 (19%)
Mean time to failure, months (SD) 67.6 (72.2)
Failure – initial management, N (%)
DVIU 8 (13%)
Urethroplasty 3 (5%)
SP tube 1 (2%)

Ventral onlay buccal mucosa urethroplasty is the workhorse of bulbar urethroplasty for many reconstructive surgeons. Easy visualization of the corpus spongiosum and urethra, excellent support of the free graft with ventral spongioplasty, and optimal access to the most proximal portion of the bulbar urethra offer advantages over dorsal onlay. Current evidence, although of low quality, demonstrates non-inferiority of ventral onlay to dorsal. A randomized controlled trial or large pragmatic trial would be necessary to definitively answer this question. Given the similarly low rate of recurrence, such a study would require a very large sample size. Several randomized trials exist in bulbar urethroplasty, but they all compare dorsal oral mucosa graft to penile skin flap.

It is likely that the majority of case series in the literature have significant selection bias introduced by the decision to place a graft either dorsally or ventrally. In our series division of the urethral plate was performed with both ventral and dorsal onlay procedures (i.e. augmented anastomotic urethroplasty), and did not portend a higher failure rate [16]. Theorizing that the division of the plate may affect the spongiosal vascular support of the graft, we have used dorsal onlay more commonly in these settings (data not shown). Thus we have more recently used ventral onlay for strictures that do not require augmented anastomotic techniques, and therefore may be less complex.

The successful reconstructive urologist must develop skills in both ventral and dorsal onlay; the decision is complex and requires a synthesis of information including etiology, location, length and degree of narrowing of the stricture; knowledge of prior surgical interventions; and graft bed and donor site considerations. A novel application of the concept of ventral onlay free graft demonstrates its enduring value. Zinman and associates [30] recently described ventral buccal onlay for some of the most complex strictures, using the gracilis muscle flap as a vascularized bed for engraftment that can overcome severely compromised urethral pathology. The grand challenges of urethral reconstruction relate to absence of tissue for transfer, absence of tissue for coverage, and severe compromise of the urethral bed. Thus, epispadias and hypospadias, radiation, battlefield injuries, and necrotizing soft tissue infection create almost unsalvageable urethral conditions. The severe proximal bulbar and membranous urethral stricture, constrained physically by the separation of the crura, presence of the bony pubis, and watershed vascular supply between the prostatic and bulbar urethra, prevent the use of staged procedures with any effectiveness.

Classic ventral and dorsal onlay procedures remain the workhorse of bulbar urethra reconstruction and have been carefully described here and elsewhere in this edition. However, when prior stenting, prostatectomy, radiation, straddle injury, or pelvic fracture creates obliteration and full thickness fibrotic defects, options become limited. If the segment of abnormal urethra exceeds the elasticity and extensibility of the bulbar urethra, and the two ends cannot be reapproximated, prospects are grim. The alternatives are unsatisfactory: tubularized skin flaps, hair bearing tissue transfer, or radical solution such as forearm free flap urethra reconstruction [33]. Engineered urethra substitutes [31] and engineered epithelial grafts [32] will prove to be important future solutions to this grand challenge. In the meantime, however, the strategy described by Zinman and associates [30] represents a significant conceptual advance and alternative surgical strategy for some of the most difficult strictures.

The ability to successfully perform free graft urethroplasty in the most unfit and compromised beds is a major step forward. Applying their extensive experience using the gracilis muscle flap in rectourethral fistula repair, the buccal mucosa ventral onlay graft is re-envisioned. Until engineered solutions can provide not only urothelium and smooth muscle, but also the molecular signals for improved vascularization of the construct, the strategy described by Zinman and associates is the next best thing.


Ventral onlay buccal mucosa urethroplasty has stood the test of time and offers a straightforward successful solution for long strictures in the bulbar urethra. With outcomes comparable to dorsal onlay, a greater ease of dissection, exposure, and graft placement, it merits continued use. Conceptual advances such as the augmented anastomotic approach and the gracilis muscle support will extend its use and increase probability of long term success in patients with compromised urethras.


The Facts

Testosterone is the hormone responsible for deep voices, muscle mass, and facial and body hair patterns found in males. As men get older, the level of testosterone in the body and production of sperm gradually becomes lower, and they experience physical and psychological symptoms as a result of these low levels. This is part of the natural aging process and it is estimated that testosterone decreases about 10% every decade after men reach the age of 30.
Andropause is a condition that is associated with the decrease in the male hormone testosterone. It is unlike menopause in that the decrease in testosterone and the development of symptoms is more gradual than what occurs in women. Approximately 30% of men in their 50s will experience symptoms of andropause caused by low testosterone levels. A person experiencing andropause may have a number of symptoms related to the condition and could be at risk of other serious health conditions such as osteoporosis without proper treatment.


The decrease in testosterone is an important factor in men suspected of having andropause. However, as men age, not only does the body start making less testosterone, but also the levels of another hormone called sex hormone binding globulin (SHBG), which pulls usable testosterone from the blood, begins to increase. SHBG binds some of the available testosterone circulating in the blood. The testosterone that is not bound to the SHBG hormone is called bioavailable testosterone, meaning it is available for use by the body.
Men who experience symptoms associated with andropause have lowered amounts of bioavailable testosterone in their blood. Therefore, tissues in the body that are stimulated by testosterone receive a lower amount of it, which may cause various physical and possibly mental changes in a person such as mood swings or fatigue.

Symptoms and Complications

Although symptoms may vary from person to person, common symptoms of men going through andropause include:
• low sex drive
• difficulties getting erections or erections that are not as strong as usual
• lack of energy
• depression
• irritability and mood swings
• loss of strength or muscle mass
• increased body fat
• hot flashes
Complications associated with andropause include an increased risk of cardiovascular problems and osteoporosis (brittle bones).

Making the Diagnosis

A doctor will ask questions about how you are feeling to see if your symptoms match those of people with low testosterone. Then, a blood test is performed to check the level of testosterone in the blood.
Because there are other conditions that are associated with low testosterone levels (e.g., hypogonadism, which causes retardation of sexual growth and development; diabetes; high blood pressure), your doctor will likely do tests to rule out these possibilities before making a diagnosis of andropause.
It is important to note that many of the symptoms associated with andropause are also a normal part of aging, and they may not be reversible with treatment.

Treatment and Prevention

Replacing testosterone in the blood is the most common treatment for men going through andropause. This treatment may provide relief from the symptoms and help improve the quality of life in many cases. Lifestyle changes such as increased exercise, stress reduction, and good nutrition also help. Your doctor will help you decide if testosterone treatment is right in your situation, as treatment does have risks.
Testosterone is available in a variety of different preparations including skin patches, capsules, gels, and injections. Your doctor will help determine which treatment is best for you and will often consider your lifestyle when making this decision. Follow-up visits with your doctor will be important after the initial treatment begins. At follow-up visits, your doctor will check your response to the treatment and make adjustments, if necessary.
Skin patches: People who wear a patch containing testosterone receive the hormone through the skin. The patch allows a slow, steady release of testosterone into the blood stream. It is applied once a day to a dry area of skin on the back, abdomen, upper arms, or thighs.
Testosterone gel: This treatment is also applied directly to the skin, usually on the arms. Because the gel may transfer to other individuals through skin contact, a person must take care to wash the gel from the hands after each application.
Capsules: Taken twice daily after meals, this is yet another option for testosterone replacement. Men with liver disease, poor liver function, serious heart or kidney disease, or too much calcium in their blood should avoid testosterone capsules.
Testosterone injections: This treatment involves injections of testosterone (testosterone cypionate* and testosterone enanthate) in the muscle every 2 to 4 weeks. They may cause mood swings due to changes in testosterone levels.
Testosterone should not be taken by any man with prostate or breast cancer. If you have heart disease, are taking some medications such as blood thinners, have an enlarged prostate, or have kidney or liver disease, you will need to discuss with your doctor whether or not testosterone therapy is right for you.

Ureteropelvic Junction Obstruction

What is Ureteropelvic Junction Obstruction?

Ureteropelvic junction (UPJ) obstruction is when part of the kidney is blocked. Most often it is blocked at the renal pelvis. This is where the kidney attaches to one of the ureters (the tubes that carry urine to the bladder). The blockage slows or stops the flow of urine out of the kidney. Urine can then build up and damage the kidney. Sometimes surgery is needed to improve the flow of urine and other times the problem will improve on its own.

What Happens under Normal Conditions?

Kidneys make urine by filtering the blood, and removing waste, salts and water. The urine drains from the kidney into the renal pelvis and then into the ureter. Each kidney must have at least 1 working ureter (some have 2) to carry the urine from the kidney to the bladder.


Most often UPJ obstruction is congenital. This means that children are born with this health issue. It is not known how to prevent it. One in 1,500 children are born with this problem. The blockage occurs as the kidney is forming. Today most cases are found using ultrasound before birth. Though it occurs less often in adults, UPJ obstruction may happen after kidney stones, surgery or upper urinary tract swelling.
In UPJ obstruction, the kidney makes urine faster than it can be drained through the renal pelvis into the ureter. This causes urine to pool in the kidney, which leads to kidney swelling (hydronephrosis). Often, only 1 kidney is affected. The enlarged kidney is easily seen on ultrasound. For this reason, a doctor can often predict UPJ obstruction before a baby is born.


With the use of ultrasound, most cases are found long before birth. After birth, signs in infants and children are:
• abdominal mass
• urinary tract infection with fever
• flank pain (pain in the upper abdomen or back, mostly with fluid intake)
• kidney stones
• bloody urine
• vomiting
• poor growth in infants
UPJ obstruction may also cause pain without an infection.
Some cases of UPJ obstruction are not clear. Urine may drain normally at times, and at other times be blocked. This causes pain that comes and goes. The general belief is that most children are not in pain unless the urine becomes infected or the blockage gets worse.


While ultrasound helps your doctor see the kidneys, more tests are needed to confirm UPJ obstruction. To make a proper diagnosis, your urologist must see how well urine is produced and drained. There are several tests that can be done.
Blood samples and urine samples may be taken. The BUN (blood urea nitrogen) and creatinine tests find if the kidney is working well as it filters the blood.
An intravenous pyelogram (IVP) was often used in the past. In this test, a dye is injected into the bloodstream. An X-ray is used to see the kidneys remove the dye from the blood. As the dye passes through urine, your doctor can see if the kidney, renal pelvis and ureter look normal.
A nuclear renal scan is similar to an IVP but is more modern. This test uses radioactive material instead of dye. The material can be seen with a special camera. This test gives the doctor good information about how the kidney is working and how much blockage there is.
CT scans are sometimes used in the emergency room to find out why children are having severe pain. A CT scan can easily show the obstructed kidney if that is the cause of the pain. Magnetic resonance imaging (MRI) is also used to look at the kidneys, ureters and the bladder. But MRI is expensive and not used everywhere.
Siblings need screening for UPJ obstruction only if they show signs. There have been some cases in which several members of a family have UPJ obstruction, but the majority of cases are individual.


Treatment is not always necessary, and experts have different opinions. It is important to know that poor drainage in infants and children younger than 18 months may be temporary. Many infants with good kidney function and poor drainage at first will have much improvement after a few months. On the other hand, in some infants the obstruction won’t improve it will get worse.
Young patients with an enlarged kidney are first followed with repeat ultrasounds and, if there is any concern, repeat nuclear scans. Sudden improvement can occur. If so, it often occurs in the first 18 months of life. If urine flow does not improve for an infant and obstruction remains, then surgery is needed. Adults may find treatment in other ways.

Open Surgery

The classic treatment for infants is an operation called pyeloplasty. In this surgery the UPJ is removed, and the ureter is reattached to the renal pelvis to create a wide opening. This lets the urine drain quickly and easily. It also relieves symptoms and the risk of infection. The surgeon’s cut is usually 2 to 3 inches long, just below the ribs. This process usually takes a few hours with a great success rate (95% success). The patient may have to stay in the hospital for a day or 2 after surgery. Drainage tubes can be used to promote healing.

Minimally Invasive Surgery

Newer surgical options are less invasive, such as:
1. laparoscopic pyeloplasty with or without a surgical robot, or
2. internal incision of the UPJ using a camera and scope inserted through the bladder

Laparoscopic Pyeloplasty

In this method the surgeon works through a small cut in the abdominal wall. A surgical robot can help guide the tools. The clear advantages of this method are less pain and nausea, especially in older children and adults. But scarring in the abdomen can result. This treatment has led to very successful results.

Internal Incision

With this option a wire is inserted through the ureter. This wire is used to cut the tight and narrow UPJ from the inside. A special ureteral drain is left in for a few weeks and then removed. The UPJ heals in a more open manner but the surgery may need to be repeated. The success rates are lower than with open or minimally invasive surgery. But the advantages also include less pain and nausea.


Prostate cancer in detail

Prostate cancer affects the prostate gland, the gland that produces some of the fluid in semen and plays a role in urine control in men.
The prostate gland is located below the bladder and in front of the rectum.
In the India, it is the Second most common cancer in men, but it is also treatable if found in the early stages.
In 2017, the American Cancer Society predicts that there will be around 161,360 new diagnoses of prostate cancer, and that around 26,730 fatalities will occur because of it.
Regular testing is crucial as the cancer needs to be diagnosed before metastasis.
Fast facts on prostate cancer:

Here are some key points about the prostate cancer. More detail is in the main article.
o The prostate gland is part of the male reproductive system.
o Prostate cancer is the most common cancer in men.
o It is treatable if diagnosed early, before it spreads.
o If symptoms appear, they include problems with urination.
o Regular screening Is the best way to detect it in good time.


Prostate cancer is the most common cancer affecting men.
There are usually no symptoms during the early stages of prostate cancer. However, if symptoms do appear, they usually involve one or more of the following:
• frequent urges to urinate, including at night
• difficulty commencing and maintaining urination
• blood in the urine
• painful urination and, less commonly, ejaculation
• difficulty achieving or maintaining an erection may be difficult
Advanced prostate cancer can involve the following symptoms:
• bone pain, often in the spine, femur, pelvis, or ribs
• bone fractures
If the cancer spreads to the spine and compresses the spinal cord, there may be:
• leg weakness
• urinary incontinence
• fecal incontinence


Treatment is different for early and advanced prostate cancers.
Early stage prostate cancer

If the cancer is small and localized, it is usually managed by one of the following treatments:
Watchful waiting or monitoring:
PSA blood levels are regularly checked, but there is no immediate action. The risk of side-effects sometimes outweighs the need for immediate treatment for this slow-developing cancer.
Radical prostatectomy:
The prostate is surgically removed. Traditional surgery requires a hospital stay of up to 10 days, with a recovery time of up to 3 months. Robotic keyhole surgery involves a shorter hospitalization and recovery period, but it can be more expensive. Patients should speak to their insurer about coverage.
Radioactive seeds are implanted into the prostate to deliver targeted radiation treatment.
Conformal radiation therapy: Radiation beams are shaped so that the region where they overlap is as close to the same shape as the organ or region that requires treatment. This minimizes healthy tissue exposure to radiation.
Intensity modulated radiation therapy: Beams with variable intensity are used. This is an advanced form of conformal radiation therapy.
In the early stages, patients may receive radiation therapy combined with hormone therapy for 4 to 6 months.
Treatment recommendations depend on individual cases. The patient should discuss all available options with their urologist or oncologist.
Advanced prostate cancer

Advanced cancer is more aggressive and will have spread further throughout the body.
Chemotherapy may be recommended, as it can kill cancer cells around the body.
Androgen deprivation therapy (ADT), or androgen suppression therapy, is a hormone treatment that reduces the effect of androgen. Androgens are male hormones that can stimulate cancer growth. ADT can slow down and even stop cancer growth by reducing androgen levels.
The patient will likely need long-term hormone therapy.
Even if the hormone therapy stops working after a while, there may be other options. Participation in clinical trials is one option that a patient may wish to discuss with the doctor.
Radical prostatectomy is not currently an option for advanced cases, as it does not treat the cancer that has spread to other parts of the body.


As the prostate is directly involved with sexual reproduction, removing it affects semen production and fertility.
Radiation therapy affects the prostate tissue and often reduces the ability to father children. The sperm can be damaged and the semen insufficient for transporting sperm.
Non-surgical options, too, can severely inhibit a man’s reproductive capacity.
Options for preserving these functions can include donating to a sperm bank before surgery, or having sperm extracted directly from the testicles for artificial insemination into an egg. However, the success of these options is never guaranteed.
Patients with prostate cancer can speak to a fertility doctor if they still intend to father children.

What causes prostate cancer?

The prostate is a walnut-sized exocrine gland. This means that its fluids and secretions are intended for use outside of the body.
The prostate produces the fluid that nourishes and transports sperm on their journey to fuse with a female ovum, or egg, and produce human life. The prostate contracts and forces these fluids out during orgasm.
The protein excreted by the prostate, prostate-specific antigen (PSA), helps semen retain its liquid state. An excess of this protein in the blood is one of the first signs of prostate cancer.
The urethra is tube through which sperm and urine exit the body. It also passes through the prostate.
As such, the prostate is also responsible for urine control. It can tighten and restrict the flow of urine through the urethra using thousands of tiny muscle fibers.

How does it start?

It usually starts in the glandular cells. This is known as adenocarcinoma. Tiny changes occur in the shape and size of the prostate gland cells, known as prostatic intraepithelial neoplasia (PIN). This tends to happen slowly and does not show symptoms until further into the progression.
Nearly 50 percent of all men over the age of 50 years have PIN. High-grade PIN is considered pre-cancerous, and it requires further investigation. Low-grade PIN is not a cause for concern.
Prostate cancer can be successfully treated if it is diagnosed before metastasis, but if it spreads, it is more dangerous. It most commonly spreads to the bones.


Staging takes into account the size and extent of the tumor and the scale of the metastasis (whether it has traveled to other organs and tissues).
At Stage 0, the tumor has neither spread from the prostate gland nor invaded deeply into it. At Stage 4, the cancer has spread to distant sites and organs.


A doctor will carry out a physical examination and enquire about any ongoing medical history. If the patient has symptoms, or if a routine blood test shows abnormally high PSA levels, further examinations may be requested.

Tests may include:
• a digital rectal examination (DRE), in which a doctor will manually check for any abnormalities of the prostate with their finger
• a biomarker test checking the blood, urine, or body tissues of a person with cancer for chemicals unique to individuals with cancer
If these tests show abnormal results, further tests will include:
• a PCA3 test examining the urine for the PCA3 gene only found in prostate cancer cells
• a transrectal ultrasound scan providing imaging of the affected region using a probe that emits sounds
• a biopsy, or the removal of 12 to 14 small pieces of tissue from several areas of the prostate for examination under a microscope
These will help confirm the stage of the cancer, whether it has spread, and what treatment is appropriate.
To track any spread, or metastasis, doctors may use a bone, CT scan, or MRI scan.

Erectile dysfunction (ED)

Erectile dysfunction (ED), also known as impotence, is a type of sexual dysfunction characterized by the inability to develop or maintain an erection of the penis during sexual activity. Erectile dysfunction can have psychological consequences as it can be tied to relationship difficulties and self-image.
A physical cause can be identified in about 80% of cases.These include cardiovascular disease, diabetes mellitus, neurological problems such as following prostatectomy, hypogonadism, and drug side effects. Psychological impotence is where erection or penetration fails due to thoughts or feelings; this is somewhat less frequent, in the order of about 10% of cases.In psychological impotence, there is a strong response to placebo treatment.
Treatment involves addressing the underlying causes, lifestyle modifications, and addressing psychosocial issues. In many cases, a trial of pharmacological therapy with a PDE5 inhibitor, such as sildenafil, can be attempted. In some cases, treatment can involve inserting prostaglandin pellets into the urethra, injecting smooth muscle relaxants and vasodilators into the penis, a penile prosthesis, a penis pump, or vascular reconstructive surgery. It is the most common sexual problem in men.

Who Gets ED?

Sexual dysfunction and ED become more common as men age. The percentage of complete ED increases from 5% to 15% as age increases from 40 to 70 years. But this does not mean growing older is the end of your sex life. ED can be treated at any age. Also, ED may be more common in Hispanic men and in those with a history of diabetes, obesity, smoking, and hypertension. Research shows that African-American men sought medical care for ED twice the rate of other racial groups.
The Mechanics of ED

An erection occurs when blood fills two chambers known as the corpora cavernosa. This causes the penis to expand and stiffen, much like a balloon as it is filled with air. The process is triggered by impulses from the brain and genital nerves. Anything that blocks these impulses or restricts blood flow to the penis can result in ED.

Causes of ED: Chronic Disease

The link between chronic disease and ED is most striking for diabetes. Men who have diabetes are two to three times more likely to have erectile dysfunction than men who do not have diabetes. Among men with erectile dysfunction, those with diabetes may experience the problem as much as 10 to 15 years earlier than men without diabetes. Yet evidence shows that good blood sugar control can minimize this risk. Other conditions that may cause ED include cardiovascular disease, atherosclerosis (hardening of the arteries), kidney disease, and multiple sclerosis. These illnesses can impair blood flow or nerve impulses throughout the body.

Causes of ED: Lifestyle

Lifestyle choices that impair blood circulation can contribute to ED. Smoking, excessive drinking, and drug abuse may damage the blood vessels and reduce blood flow to the penis. Smoking makes men with atherosclerosis particularly vulnerable to ED. Being overweight and getting too little exercise also contribute to ED. Studies indicate that men who exercise regularly have a lower risk of ED.

Causes of ED: Psychological

ED usually has something physical behind it, particularly in older men. But psychological factors can be a factor in many cases of ED. Experts say stress, depression, poor self-esteem, and performance anxiety can short-circuit the process that leads to an erection. These factors can also make the problem worse in men whose ED stems from something physical.

Urinary Incontinence

What is urinary incontinence?

Urinary incontinence is a common problem.
Urinary incontinence is when a person cannot prevent urine from leaking out.
It can be due to stress factors, such as coughing, it can happen during and after pregnancy, and it is more common with conditions such as obesity.
The chances of it happening increase with age.
Bladder control and pelvic floor, or Kegel, exercises can help prevent or reduce it.


Treatment will depend on several factors, such as the type of incontinence, the patient’s age, general health, and their mental state.
Stress incontinence
Pelvic floor exercises, also known as Kegel exercises, help strengthen the urinary sphincter and pelvic floor muscles – the muscles that help control urination.

Bladder training

Delaying the event: The aim is to control urge. The patient learns how to delay urination whenever there is an urge to do so.
Double voiding: This involves urinating, then waiting for a couple of minutes, then urinating again.
Toilet timetable: The person schedules bathroom at set times during the day, for example, every 2 hours.
Bladder training helps the patient gradually regain control over their bladder.

Medications for urinary incontinence

If medications are used, this is usually in combination with other techniques or exercises.
The following medications are prescribed to treat urinary incontinence:
• Anticholinergics calm overactive bladders and may help patients with urge incontinence.
• Topical estrogen may reinforce tissue in the urethra and vaginal areas and lessen some of the symptoms.
• Imipramine (Tofranil) is a tricyclic antidepressant.

Medical devices

The following medical devices are designed for females.
Urethral inserts: A woman inserts the device before activity and takes it out when she wants to urinate.
Pessary: A rigid ring inserted into the vagina and worn all day. It helps hold the bladder up and prevent leakage.
Radiofrequency therapy: Tissue in the lower urinary tract is heated. When it heals, it is usually firmer, often resulting in better urinary control.
Botox (botulinum toxin type A): Injected into the bladder muscle, this can help those with an overactive bladder.
Bulking agents: Injected into tissue around the urethra, these help keep the urethra closed.
Sacral nerve stimulator: This is implanted under the skin of the buttock. A wire connects it to a nerve that runs from the spinal cord to the bladder. The wire emits an electrical pulse that stimulates the nerve, helping bladder control.


Surgery is an option if other therapies do not work. Women who plan to have children should discuss surgical options with a doctor before making the decision.
Sling procedures: A mesh is inserted under the neck of the bladder to help support the urethra and stop urine from leaking out.
Colposuspension: Lifting the bladder neck can help relieve stress incontinence.
Artificial sphincter: An artificial sphincter, or valve, may be inserted to control the flow of urine from the bladder into the urethra.

Other options

Urinary Catheter: A tube that goes from the bladder, through the urethra, out of the body into a bag which collects urine.
Absorbent pads: A wide range of absorbent pads is available to purchase at pharmacies and supermarkets, as well as online.


The causes and the type of incontinence are closely linked.

Stress incontinence

Factors include:
• pregnancy and childbirth
• menopause, as falling estrogen can make the muscles weaker
• hysterectomy and some other surgical procedures
• age
• obesity

Urge incontinence

The following causes of urge incontinence have been identified:
• cystitis, an inflammation of the lining of the bladder
• neurological conditions, such as multiple sclerosis (MS), stroke, and Parkinson’s disease
• enlarged prostate, which can cause the bladder to drop, and the urethra to become irritated

Overflow incontinence

This happens when there is an obstruction or blockage to the bladder. The following may cause an obstruction:
• an enlarged prostate gland
• a tumor pressing against the bladder
• urinary stones
• constipation
• urinary incontinence surgery which went too far

Total incontinence

This can result from:
• an anatomical defect present from birth
• a spinal cord injury that impairs the nerve signals between the brain and the bladder
• a fistula, when a tube or channel develops between the bladder and a nearby area, usually the vagina

Other causes:

These include:
• some medications, especially some diuretics, antihypertensive drugs, sleeping tablets, sedatives, and muscle relaxants
• alcohol
• urinary tract infections (UTIs)


The type of urinary incontinence is normally linked to the cause.
They include:
• Stress incontinence: Urine leaks out while coughing, laughing, or doing some activity, such as running or jumping
• Urge incontinence: There is a sudden and intense urge to urinate, and urine leaks at the same time or just after.
• Overflow incontinence: The inability to empty the bladder completely can result in leaking
• Total incontinence: The bladder cannot store urine
• Functional incontinence: Urine escapes because a person cannot reach the bathroom in time, possibly due to a mobility issue.
• Mixed incontinence: A combination of types


The main symptom is the unintentional release (leakage) of urine. When and how this occurs will depend on the type of urinary incontinence.
Stress incontinence
This is the most common kind of urinary incontinence, especially among women who have given birth or gone through the menopause.
In this case “stress” refers to physical pressure, rather than mental stress. When the bladder and muscles involved in urinary control are placed under sudden extra pressure, the person may urinate involuntarily.
The following actions may trigger stress incontinence:
• coughing, sneezing, or laughing
• heavy lifting
• exercise
Urge incontinence
Also known as reflex incontinence or “overactive bladder,” this is the second most common type of urinary incontinence. There is a sudden, involuntary contraction of the muscular wall of the bladder that causes an urge to urinate that cannot be stopped.
When the urge to urinate comes, the person has a very short time before the urine is released, regardless of what they try to do.
The urge to urinate may be caused by:
• a sudden change in position
• the sound of running water
• sex, especially during orgasm
Bladder muscles can activate involuntarily because of damage to the nerves of the bladder, the nervous system, or to the muscles themselves.
Overflow incontinence
This is more common in men with prostate gland problems, a damaged bladder, or a blocked urethra. An enlarged prostate gland can obstruct the bladder.
The bladder cannot hold as much urine as the body is making, or the bladder cannot empty completely, causing small amounts of urinary leakage.
Often, patients will need to urinate frequently, and they may experience “dribbling” or a constant dripping of urine from the urethra.
Mixed incontinence
There will be symptoms of both stress and urge incontinence.
Functional incontinence
With functional incontinence, the person knows there is a need to urinate, but cannot make it to the bathroom in time due to a mobility problem.
Common causes of functional incontinence include:
• confusion
• dementia
• poor eyesight or mobility
• poor dexterity, making it hard to cannot unbutton the pants
• depression, anxiety, or anger can lead to an unwillingness to use the bathroom
Functional incontinence is more prevalent among elderly people and is common in nursing homes.
Total incontinence
This either means that the person leaks urine continuously, or has periodic uncontrollable leaking of large amounts of urine.
The patient may have a congenital problem (born with a defect), there may be an injury to the spinal cord or urinary system, or there may be a hole (fistula) between the bladder and, for example, the vagina.

Risk factors

The following are risk factors linked to urinary incontinence:
Obesity: This puts extra pressure on the bladder and surrounding muscles. It weakens the muscles, making leakage more likely when the person sneezes or coughs.
Smoking: This can lead to a chronic cough, which may result in episodes of incontinence.
Gender: Women have a higher chance of experiencing stress incontinence than men, especially if they have had children.
Old age: The muscles in the bladder and urethra weaken with age.
Some diseases and conditions: Diabetes, kidney disease, spinal cord injury, and neurologic diseases, for example, a stroke, increase the risk.
Prostate disease: Incontinence may present after prostate surgery or radiation therapy.


Ways to diagnose urinary incontinence include:
A bladder diary: The person records how much they drink, when urination occurs, how much urine is produced, and the number of episodes of incontinence.
Physical exam: The doctor may examine the vagina and check the strength of the pelvic floor muscles. They may examine the rectum of a male patient, to determine whether the prostate gland is enlarged.
Urinalysis: Tests are carried out for signs of infection and abnormalities.
Blood test: This can assess kidney function.
Postvoid residual (PVR) measurement: This assesses how much urine is left in the bladder after urinating.
Pelvic ultrasound: Provides an image and may help detect any abnormalities.
Stress test: The patient will be asked to apply sudden pressure while the doctor looks out for loss of urine.
Urodynamic testing: This determines how much pressure the bladder and urinary sphincter muscle can withstand.
Cystogram: An X-ray procedure provide an image of the bladder.
Cystoscopy: A thin tube with a lens at the end is inserted into the urethra. The doctor can view any abnormalities in the urinary tract.


The inability to retain urine can sometimes lead to discomfort, embarrassment, and sometimes other physical problems.
These include:
Skin problems – a person with urinary incontinence is more likely to have skin sores, rashes, and infections because the skin is wet or damp most of the time. This is bad for wound healing and also promotes fungal infections.
Urinary tract infections – long-term use of a urinary catheter significantly increases the risk of infection.
Prolapse – part of the vagina, bladder, and sometimes the urethra can fall into the entrance of the vagina. This is usually caused by weakened pelvic floor muscles.
Embarrassment can cause people to withdraw socially, and this can lead to depression. Anyone who is concerned about urinary incontinence should see a doctor, as help may be available

Urethral Stricture

What is urethral stricture?

The urethra is a tube that carries urine from the bladder so it can be expelled from the body.
Usually the urethra is wide enough for urine to flow freely through it. When the urethra narrows, it can restrict urinary flow. This is known as a urethral stricture.
Urethral stricture is a medical condition that mainly affects men.

What are the causes of urethral stricture?

Urethral stricture involves constriction of the urethra. This is usually due to tissue inflammation or the presence of scar tissue. Scar tissue can be a result of many factors. Young boys who have hypospadias surgery (a procedure to correct an underdeveloped urethra) and men who have penile implants have a higher chance of developing urethral stricture.
A straddle injury is a common type of trauma that can lead to urethral stricture. Examples of straddle injuries include falling on a bicycle bar or getting hit in the area close to the scrotum.
Other possible causes of urethral stricture include:
• pelvic fractures
• catheter insertion
• radiation
• surgery performed on the prostate
• benign prostatic hyperplasia
Rare causes include:
• a tumor located in close proximity to the urethra
• untreated or repetitive urinary tract infections
• the sexually transmitted infections (STIs) gonorrhea or chlamydia

What are the risk factors for urethral stricture?

Some men have an elevated risk of developing urethral stricture, especially those who have:
• had one or more STIs
• had a recent catheter (a small, flexible tube inserted into the body to drain urine from the bladder) placement
• had urethritis (swelling and irritation in the urethra), possibly due to infection
• an enlarged prostate

What are the symptoms of urethral stricture?

Urethral stricture can cause numerous symptoms, ranging from mild to severe. Some of the signs of a urethral stricture include:
• weak urine flow or reduction in the volume of urine
• sudden, frequent urges to urinate
• a feeling of incomplete bladder emptying after urination
• frequent starting and stopping urinary stream
• pain or burning during urination
• inability to control urination (incontinence)
• pain in the pelvic or lower abdominal area
• urethral discharge
• penile swelling and pain
• presence of blood in the semen or urine
• darkening of the urine
• inability to urinate (this is very serious and requires immediate medical attention)

How is urethral stricture diagnosed?

Doctors may use several approaches to diagnose urethral stricture.
Reviewing your symptoms and medical history
You can self-report the symptoms mentioned above. Your doctor may also ask about past illnesses and medical procedures to determine whether one or more risk factors are present.
Performing a physical examination
A simple physical examination of the penis area can help the doctor identify the presence of a urinary stricture. For instance, the doctor will be able to readily observe redness (or urethral discharge) and find out if one or more areas are hard or swollen.
Conducting tests
To make a definite diagnosis of a urethral stricture, the doctor may also decide to perform one or more of the following tests:
• measuring the rate of flow during urination
• analyzing the physical and chemical properties of urine to determine if bacteria (or blood) are present
• cystoscopy: inserting a small tube with a camera into the body to view the inside of the bladder and urethra (the most direct way to check for stricture)
• measuring the size of the urethral opening
• tests for chlamydia and gonorrhea

What are the treatment methods for urethral stricture?

Treatment depends on the severity of the condition.
The primary mode of treatment is to make the urethra wider using a medical instrument called a dilator. This is an outpatient procedure, meaning you won’t have to spend the night at the hospital. A doctor will begin by passing a small wire through the urethra and into the bladder to begin to dilate it. Over time, larger dilators will gradually increase the width of the urethra.
Another nonsurgical option is permanent urinary catheter placement. This procedure is usually done in severe cases. It has risks, such as bladder irritation and urinary tract infection.
Surgery is another option. An open urethroplasty is an option for longer, more severe strictures. This procedure involves removing affected tissue and reconstructing the urethra. Results vary based on stricture size.
Urine flow diversion
In severe cases, a complete urinary diversion procedure may be necessary. This surgery permanently reroutes the flow of urine to an opening in the abdomen. It involves using part of the intestines to help connect the ureters to the opening. Urinary diversion is usually only performed if the bladder is severely damaged or if it needs to be removed.

How can I prevent urethral stricture?

It’s not always possible to prevent urethral stricture. Since STIs are one cause, using protection during sexual contact can prevent some cases. However, injuries and other medical conditions associated with urethral stricture can’t always be avoided.
It’s important to see a doctor right away if you’re experiencing symptoms of urethral stricture. Treating the problem quickly is the best way to avoid serious complications.

What is the long-term outlook?

Many people have a good outcome after treatment for a urethral stricture. You may need future treatments as well if the stricture is the result of scar tissue.
In some cases, stricture can cause urinary retention, the inability to urinate due to complete blockage in the urethra. This is a potentially dangerous condition. You should call your doctor right away if you experience symptoms of stricture and are unable to urinate.

Urinary Stone

Important Facts and Overview

» A kidney stone, also known as a renal calculus is a solid concretion or crystal aggregation formed in the kidneys from dietary minerals in the urine.
» Urolithiasis is one of the most common diseases, with approximately 17.6% incidence in India. Although most patients have only one stone episode, 25% of patients experience recurrent stone formation. UL therefore has a significant impact on quality of life and socioeconomic factors.
» • Urinary stones are typically classified by their location in the kidney (nephrolithiasis), ureter (ureterolithiasis), or bladder (cystolithiasis), or by their chemical composition (calcium-containing, struvite, uric acid, Xanthine or other compounds).
» About 60-80% of those with kidney stones are men.
» Urinary stones are highly prevalent due to the hot and humid climate, poor water intake and urinary infections. Patients routinely get pain in the flanks, vomiting, burning while passing urine. Occasionally they also get fever and blood in the urine.
» Two very important facts to be noted are:

1. 20% of urinary stone patients do not have any complaints and hence are detected in screening or health check up programs.
2. 3% of patients with kidney stones present with kidney failure. .
» Sonography is the best and the most routine test performed to detect urinary stones. Blood and urine tests along with X-ray test are also required.


» The existence of kidney stones was first recorded thousands of years ago, and lithotomy for the removal of urinary stones is one of the earliest known surgical procedures.
» In 1901, a stone discovered in the pelvis of an ancient Egyptian mummy was dated to 4,800 BC.
» Part of the Hippocratic Oath suggests there were practicing surgeons in ancient Greece to whom physicians were to defer for lithotomies. Medical texts from ancient India, Persia, Greece and Rome all mentioned calculous diseases.
» Famous people with kidney stones include Napoleon I, Napoleon III, Peter the Great, Louis XIV, George IV, Oliver Cromwell, Lyndon B. Johnson, Benjamin Franklin, Michel de Montaigne, Isaac Newton, William Harvey, Herman Boerhaave, and Antonio Scarpa.
» New techniques in lithotomy began to emerge starting in 1520, but the operation remained risky. After Henry Jacob Bigelow popularized the technique of litholapaxy in 1878, the mortality rate dropped from about 24% to 2.4%. However, other treatment techniques continued to produce a high level of mortality, especially among inexperienced urologists.
» In 1980, Dornier MedTech introduced extracorporeal shock wave lithotripsy for breaking up stones via acoustical pulses, and this technique has since come into widespread use.

How Common are Urinary Stones?

Kidney stones affect all geographical, cultural, and racial groups.

» The lifetime risk is about 10 to 15% in the developed world, but can be as high as 20 to 25% in the Eastern world. The increased risk of dehydration in hot climates, coupled with a diet 50% lower in calcium and 250% higher in oxalates compared to Western diets, accounts for the higher net risk in the Middle East. In the Middle East, uric acid stones are more common than calcium-containing stones.
» The number of deaths due to kidney stones is estimated at 19,000 per year being fairly consistent between 1990 and 2010.
» In North America and Europe, the annual incidence (number of new cases per year) of kidney stones is roughly 0.5%. In the United States, the prevalence (frequency in the population) of urolithiasis has increased from 3.2% to 5.2% from the mid-1970s to the mid-1990s.
» About 65% of those with kidney stones are men. Men most commonly experience their first episode between 30 and 40 years of age, whereas for women, the age at first presentation is somewhat later. The age of onset shows a bimodal distribution in women, with episodes peaking at 35 and 55 years.
» Recurrence rates are estimated at 50% over a 10-year and 75% over 20-year period, with some people experiencing ten or more episodes over the course of a lifetime.

What are urinary stones made of? (Pathophysiology of Urinary Stones)

A majority of kidney stones are calcium stones, with calcium oxalate (CaOx) and calcium phosphate (CaP) accounting for approximately 80% of all of these stones, uric acid (UA) about 9%, and struvite (magnesium ammonium phosphate hexahydrate, from infection by bacteria that possess the enzyme urease) approximately 10%, leaving only 1% for all the rest (cystine, drug stones, ammonium acid urate).

» A total of 1050 urinary calculi (900 renal, 150 ureteric) were analyzed by X-ray diffraction crystallography technique, in patients managed at All India Institute of Medical Sciences. The stone fragments were collected after extracorporeal shock-wave lithotripsy, or retrieval by endoscopic (percutaneous nephrolithotomy, ureterorenoscopy), laparoscopic and various open surgical procedures. The structural analysis of the stones was done using X-ray diffraction crystallography.
» Of the 1050 stones analyzed, 977 (93.04%) were calcium oxalate stones, out of which 80% were calcium oxalate monohydrate (COM) and 20% were calcium oxalate dihydrate (COD). Fifteen were struvite (1.42%) and 19 were apatite (1.80%). Ten were uric acid stones (0.95%) and the remaining 29 (2.76%) were mixed stones (COM + COD and calcium oxalate + uric acid, calcium oxalate + calcium phosphate, and calcium phosphate + magnesium ammonium phosphate). .


Urinary stones are typically classified by:

A – Their location in the kidney (nephrolithiasis), ureter (ureterolithiasis), or bladder (cystolithiasis), or

B – Chemical Composition (calcium-containing, struvite, uric acid, or other compounds).

Risk Factors

1. Dehydration from low fluid intake is a major factor in stone formation. .
2. High dietary intake of animal protein, sodium, refined sugars, fructose, and oxalate, increase the risk of kidney stone formation.
3. Kidney stones can result from an underlying metabolic condition, such as hyperparathyroidism, distal renal tubular acidosis, primary hyperoxaluria, or medullary sponge kidney. 3–20% of people who form kidney stones have medullary sponge kidney.
4. Kidney stones are more common in people with Crohn’s disease. Crohn’s disease is associated with hyperoxaluria and malabsorption of magnesium.

A person with recurrent kidney stones may be screened for such disorders. This is typically done with a 24-hour urine collection. The urine is analyzed for features that promote stone formation.

The Role of Global Warming
Epidemiologic studies have shown that regions with higher average temperatures have the highest stone rates. The correlation between increased environmental temperature and increased number of stone events supports the conclusion that global warming has an impact on the development of stones. It has been predicted that, based on the effects of global warming, the percentage of people living in areas designated as high risk for kidney stone formation would increase from 40% in 2000 to 56% by 2050, and up to 70% by 2095. This would result in a significant “climate-related” increase in kidney stone events.


Diagnosis of kidney stones is made on the basis of information obtained from

1. the history, . .
2. physical examination,
3. urinalysis, and
4. radiographic studies.

Clinical diagnosis is usually made on the basis of the location and severity of the pain, which is typically colicky in nature (comes and goes in spasmodic waves). Pain in the back and flank occurs when calculi produce an obstruction in the kidney.
Along with pain, patient may present with vomiting or blood in the urine (haematuria) or pain while passing urine (dysuria).

Imaging studies

Calcium-containing stones are relatively radiodense, and they can often be detected by a traditional radiograph of the abdomen that includes the kidneys, ureters, and bladder (X Ray KUB film). Some 60% of all renal stones are radiopaque. In general, calcium phosphate stones have the greatest density, followed by calcium oxalate and magnesium ammonium phosphate stones. Cystine calculi are only faintly radiodense, while uric acid stones are usually entirely radiolucent (not seen on Xray).

Where available, a CT Scan is the diagnostic modality of choice in the radiographic evaluation of suspected nephrolithiasis. All stones are detectable on CT scans except very rare stones composed of certain drug residues in the urine, such as from indinavir.

Where a CT scan is unavailable, an intravenous pyelogram may be performed to help confirm the diagnosis of urolithiasis. This involves intravenous injection of a contrast agent followed by a KUB film.
Ultrasound imaging the stone is blocking the outflow of urine. Radiolucent stones, which do not appear on KUB, may show up on ultrasound imaging studies. Other advantages of renal ultrasonography include its low cost and absence of radiation exposure. Ultrasound imaging is useful for detecting stones in situations where X-rays or CT scans are discouraged, such as in children or pregnant women.

Laboratory examination

Microscopic examination of the urine, which may show red blood cells, bacteria, leukocytes,urinary casts and crystals. Also important is the urinary pH.
Urine culture to identify any infecting organisms present in the urinary tract and sensitivity to determine the susceptibility of these organisms to specific antibiotics;
Complete blood count (CBC), looking for increase neutrophil count suggestive of bacterial infection, as seen in the setting of struvite stones or any stone with kidney infection;
Renal function blood tests (Creatinine, Urea)
to look for loss in renal function.
Blood test for abnormally high blood calcium blood levels (hypercalcemia);
24 hour urine collection to measure total daily urinary volume, magnesium, sodium, uric acid, calcium, citrate, oxalate and phosphate;
Chemical analysis of stones: collection of stones (by urinating through a Stone-Screen kidney stone collection cup or a simple tea strainer) is useful. Chemical analysis of collected stones can establish their composition, which in turn can help to guide future preventive and therapeutic management.


Most stones less than 6 mm pass spontaneously.
Increased and regular fluid intake forms the mainstay of treatment. Analgesics (pain killers) are given as and when required.
Medications like alpha blockers (Tamsulosin or Alfuzosin) help in spontaneous passage of small stones.
Surgical or Minimal Invasive Treatment of Urinary Stones
Beginning in the mid-1980s, less invasive treatments such as extracorporeal shock wave lithotripsy and endoscopic surgery began to replace open surgery as the modalities of choice for the surgical management of urolithiasis.

Lithotripsy (ESWL)

Extracorporeal shock wave lithotripsy (ESWL) is a noninvasive technique for the removal of kidney stones. ESWL involves the use of a lithotriptor machine to deliver externally applied, focused, high-intensity pulses of ultrasonic energy to cause fragmentation of a stone over a period of around 30–60 minutes.
It is currently used in the treatment of uncomplicated stones located in the kidney and upper ureter, provided the aggregate stone burden (stone size and number) is less than 20 mm and the anatomy of the involved kidney is normal.
However due to unpredictable and poor results and need for multiple sessions and procedures, the use of ESWL is on the decline and is being replaced by minimal invasive modalities like Ureteroscopy or PCNL.

Endoscopic Surgery

Need for endoscopic surgery arises when a patient has:

Stones larger than 8mm that are unlikely to pass
only one working kidney with stone,
bilateral obstructing stones,
a urinary tract infection or an infected kidney, or
intractable pain.
Endoscopic surgery is named as per the location of stone.

Cystolithotrity: Removal of stones in the urinary bladder.
Ureteroscopy: Removal of stones in the ureter.
PCNL (Percutaneous Nephrolithotomy): Removal of stones in the kidney. This endoscopic surgery offers the highest success rates with regards to complete stone clearance. This is now done using the MiniPCNL 5mm endoscope.
Flexible ureteroscopy (RIRS) with holmium laser has evolved in the last decade to facilitate treat kidney stones unto 1.5cm size.

Urinary Stones in Children

The prevalence of urolithiasis in children depends on socioeconomic conditions as well as ethnicity.
The incidence of urolithiasis has increased worldwide, independent of age.
Lifestyles changes especially dietary, and the obesity epidemic have been suggested as potential causes.
In underdeveloped countries, malnutrition is a major reason for the prevalence of bladder stones and ammonium urate stones in children.
Pediatric urinary stone patients belong to the high-risk group for recurrent urinary stones. As such, these patients and their families need specific therapeutic directions for effective stone prevention, adjusted to their metabolic risk. The risk may be based on anatomic or functional disorders of the urinary collecting system and/or metabolic abnormalities including genetic disorders.

Preventing Stone Recurrence

Role of Diet in formation of urinary stone
High Fluid intake is the most important dietary modification to reduce chances of stone recurrence.

A fluid intake that will achieve a urine volume of at least 2.5 liters daily
A sufficiently dilute urine will prevent the individual chemical components of stones from becoming concentrated enough to precipitate out of solution, keeping them instead in their dissolved state.
A high urine output also may reduce stone from forming through “flushing” out of stone components and prevention of urine stagnation.
In addition to stone benefits, increased water intake has been shown to have a multitude of other benefits, including improved alertness, better skin appearance, enhanced physical performance, reduced constipation.
Limit sodium intake to less than 2.3gm / day.
Consume 1,200 mg per day of dietary calcium. (The risk of developing a recurrent stone on the normal calcium diet was 51% lower than on the lower calcium diet. Supplemental calcium, in contrast, may be associated with an increased risk of stone formation.)
Increase fruit and vegetable intake.
Reduce intake of high-acid foods like aerated drinks, oil and butter.
Increase dietary citrate intake: Lemon, oranges, grapefruit juice.
Limit non-dairy animal protein.

Medical Treatment

Urine alkalinization
Medical treatment depends upon the type of stone. It does not dissolve any existent stone but may reduce the chances of reformation
The mainstay for medical management of uric acid stones is alkalinization (increasing the pH) of the urine.
Acetazolamide (Diamox) is a medication that alkalinizes the urine.
Dietary supplements are available that produce a similar alkalinization of the urine. These include sodium bicarbonate, potassium citrate, magnesium citrate. Aside from alkalinization of the urine, these supplements have the added advantage of increasing the urinary citrate level, which helps to reduce the aggregation of calcium oxalate stones.


One of the recognized medical therapies for prevention of stones is the thiazide and thiazide-like diuretics, such as chlorthalidone or indapamide. These drugs inhibit the formation of calcium-containing stones by reducing urinary calcium excretion. Sodium restriction is necessary for clinical effect of thiazides, as sodium excess promotes calcium excretion.


For people with hyperuricosuria and calcium stones, allopurinol is one of the few treatments that have been shown to reduce kidney stone recurrences. Allopurinol interferes with the production of uric acid in the liver. The drug is also used in people with gout or hyperuricemia (high serum uric acid levels).


Understanding the Prostate Gland: A Common Ageing Problem

What is the prostate gland?

The prostate is a walnut shaped gland surrounding the junction of the urinary bladder (balloon like organ that stores urine) and the urethra (tube that throws urine out through the penis). It is present in every male by birth. In adulthood, it produces a liquid that comes out in the semen along with the sperms. Its normal size ranges from 11 to 16 gm.

What are the common disease affecting the prostate gland?

There are three diseases mainly.

1. Age related prostate growth and disease

2. Prostate Infection (Prostatitis)

3. Prostate Cancer

Age related prostate growth is the most common disease. The prostate gland may increase in size with age, especially after the age of 50 years. An enlarged or sometimes even a normal sized prostate gland may compress on the urethra (tube that throws urine out through the penis). This would create difficulty in passing urine.

What are the common signs of prostate disease?

Prostate diseases can affect you in 2 ways
1 Voiding (Urine passing) symptoms: Difficulty in passing urine, prolonged time taken to pass urine, need to apply pressure to pass urine, thin or interrupted urine stream, feeling of incomplete emptying of the urinary bladder.

2 Urine Storage symptoms: Frequent desire to pass urine, unable to control the desire to pass urine with or without leakage of few drops of urine in the clothes.

Other common symptoms of prostate diseases are blood in the urine, burning while passing urine, pain in the lower abdomen while passing urine.

Do these symptoms confirm prostate disease only?

No. Similar symptoms can also be present in patients with diabetes, neurological diseases like paralysis, slipped disc compression, etc.

How does one confirm whether he has a prostate disease?

You need to consult your Urologist. Besides examination by the doctor, Sonography of the abdomen, uroflowmetry (a test to assess your urinary flow), urine test and blood tests need to be done. 2 important blood tests are Creatinine (kidney function status) and PSA (prostate cancer screening test).

Can a person prevent prostate disease?

No. But you need to modify your lifestyle with age to prevent increasing your symptoms. These are simple steps such as: Prevent constipation, Increase fibre intake in your diet, take regular fluid instead of over drinking large amount of fluid at one time, and pass urine at regular intervals instead of delaying your urination for lengthy periods.

What is the treatment for age related prostate disease?

The most important part of treatment is lifestyle modification as highlighted above.
Prostate diseases can be treated by medicines or endoscopic surgery. Majority of patients with early prostate disease can be controlled by medicines. Medicines are of various types. The size of the prostate and the age of the patient help in deciding the correct medicine. It is important to remember that medicines do not permanently cure the disease. Hence they need to be taken daily and almost life long. They do not cause any serious complications or side effects. Your Urologist would guide you your correct type and dose of medicines. Regular checkups once every 2 to 6 monthly is important to assess whether the disease is well controlled by the medicines.

When is Surgery required?

Indications for surgery include:

1. No relief with medicines.

2. Severe obstruction in the flow of urine

3. Urinary retention (total urinary blockage with need to pass a tube to remove the urine from the urinary bladder)

4. Complications like formation of stones in the urinary bladder, hernia formation, frequent bleeding in the urine, kidney failure, etc

If required, how is Surgery done?

Open prostate surgery (Scar and Stitches) is obsolete and not done anymore. Endoscopic Surgery is the curative and the best treatment for age related prostate disease. There are lot of techniques of endoscopic surgery. The three best are:


2. Plasma (Bipolar)

3. Holmium Laser resection

Basically all the 3 modalities are safe and done similarly endoscopically. The prostate gland is cut and removed endoscopically. TURP is the standard and the most well accepted treatment all over the world. The other 2 treatments are more helpful for large prostates (more than 80gm) and high risk cardiac patients.

In all the three types of endoscopic surgery, the patient is hospitalised for 2 to 3 days, a catheter (tube) is placed after the surgery to drain the urine for the initial 2 days. The amount of bleeding is almost insignificant in all the 3 types. There is no scar or hole in any of these surgeries.

Can there be any complications after endoscopic surgery?

The chances of complications after the endoscopic surgery are minimal. The common side effects are infection and stricture (obstruction in a part of urinary tube in the penis). These occur in 5 to 10%. Also there can be some loss of sexual function. These side effects are however negligible with plasma or laser technique.

Is prostate cancer curable?

Yes, if diagnosed early with the help of blood PSA test. Laparoscopic surgery can cure the prostate cancer if diagnosed at an early stage. Anyway prostate cancer is the one of the slowest growing cancers in the male population.

Direct Vision Internal Urethrotomy

Direct vision internal urethrotomy (DVIU) is surgery to repair a narrowed section of the urethra. This is referred to as a stricture. The urethra is the tube through which urine passes from the bladder to the outside of the body.

Reasons for Procedure
1. Urethral stricture is due to scarring of the urethra. This
2. Scarring may because by infection or injury. DVIU cuts
3. Through the scar tissue and
4. Opens the urethra.

Male Urethra

Urethral stricture can result in:

• Prostate problems in men
• Infections of the bladder or kidneys
• Inability to urinate or empty the bladder completely

Post-urethroplasty DVIU for isolated, recurrent strictures may be offered as a minimally invasive treatment option.