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Pocket Guidelines
2014
edition
European
Association
of Urology
Pocket Guidelines
2014 edition
European
Association
of Urology
Pocket Guidelines
2014 edition
Introduction
This 10th edition of the pocket guidelines includes many
changes and each text will list the year of update, which
should help the readers identify the2014 changes. These short
texts are an easy reference tool, but clinicians should also
consult the full text guidelines documents upon which they
are based, because the abbreviated information shows only a
fraction of the work done by the many experts involved in the
EAU guidelines panels.
Introduction
Introduction
References
Introduction
Page 7
Page 29
Page 45
Page 68
Page 85
Page 98
Page 116
Page 130
Page 22
Page 158
Page 166
Page 178
Page 189
Page 215
Page 232
Page 244
Page 261
Page 282
Page 308
Page 342
Page 353
Page 149
Priapism
Penile Curvature
Male Infertility
Male Hypogonadism
Urinary Incontinence
Urological Infections
Neuro-Urology
Urological Trauma
Pain Management & Palliative Care
Chronic Pelvic Pain
Urolithiasis
Renal Transplantation
Paediatric Urology
5
GUIDELINES ON NON-MUSCLE
INVASIVE (Ta, T1, CIS) BLADDER
CANCER
(Text update April 2014)
Introduction
The EAU Working Group has published guidelines on nonmuscle invasive bladder cancer (NMIBC). It comprises Ta and
T1 tumours as well as carcinoma in situ (CIS) according to the
TNM Classification of Malignant Tumours, 7th Edition, 2009
(Table 1).
11
12
GR
A
C
B
C
C
TURB
TURB should be performed systematically in individual
steps:
bimanual palpation under anaesthesia;
insertion of the resectoscope, under visual control
with inspection of the whole urethra;
inspection of the whole urothelial lining of the bladder;
biopsy from prostatic urethra (if indicated);
cold-cup bladder biopsies (if indicated);
resection of the tumour;
bimanual palpation after resection;
protocol formulation;
formulation of order form for pathological evaluation.
Perform resection in one piece for small papillary
tumours (< 1 cm), including part from the underlying
bladder wall.
Perform resection in fractions (including muscle tissue) for tumours > 1 cm in diameter.
Biopsies should be taken from abnormal-looking
urothelium. Biopsies from normal-looking mucosa
(trigone, bladder dome, and right, left, anterior and
posterior bladder walls) are recommended only when
cytology is positive or when exophytic tumour has a
non-papillary appearance.
Biopsy of the prostatic urethra is recommended for
cases of bladder neck tumour, when bladder CIS is
present or suspected, when there is positive cytology
without evidence of tumour in the bladder, or when
abnormalities of the prostatic urethra are visible. If
biopsy is not performed during the initial procedure, it
should be completed at the time of the second resection.
B
C
13
14
15
16
Subgroup of
highest-risk
tumours
17
18
GR
B
A
A
A
C
B
C
Intravesical chemotherapy
One immediate instillation should be administered
C
within 24 hours after TURB.
One immediate instillation of chemotherapy should
C
be omitted in any case of overt or suspected intra- or
extra-peritoneal perforation (after extensive TURB, or
bleeding requiring bladder irrigation).
The optimal schedule of further intravesical chemoC
therapy instillation and its duration is not defined and
should not exceed 1 year.
If intravesical chemotherapy is given, it is advised to
B
use the drug at its optimal pH and to maintain the
concentration of the drug during instillation by reducing fluid intake.
The length of individual instillation should be 1-2 hours. C
BCG intravesical immunotherapy
Absolute contraindications of BCG intravesical instil- C
lation are:
during the first 2 weeks after TURB;
in patients with macroscopic haematuria;
after traumatic catheterization;
in patients with symptomatic urinary tract infection.
The management of side effects after BCG intravesical C
instillation should reflect their type and grade.
BCG = bacillus Calmette-Gurin; CIS = carcinoma in situ;
MMC = mitomycin C; TUR = transurethral resection; TURB =
transurethral resection of the bladder.
19
When planning the follow-up schedule and methods, the following aspects should be considered:
The prompt detection of muscle-invasive and HG/G3 nonmuscle-invasive recurrence is crucial because a delay in
diagnosis and therapy can be life-threatening.
Tumour recurrence in the low-risk group is nearly always
low stage and LG/G1.
Small, non-invasive (Ta), LG/G1 papillary recurrence does
not present an immediate danger to the patient, and early
detection is not essential for successful therapy (LE: 2b).
Fulguration of small papillary recurrences on an outpatient
basis could be a safe option that reduces the therapeutic
burden.
The first cystoscopy after TURB at 3 months is a very
important prognostic indicator for recurrence and progression. The first cystoscopy should thus always be performed
3 months after TURB in all patients with Ta, T1 tumours and
CIS.
In tumours at low risk, the risk of recurrence after 5 recurrence-free years is low.
Discontinuation of cystoscopy or its replacement with lessinvasive methods can be considered.
In tumours originally intermediate- or high-risk, recurrences after 10 years tumour-free are not unusual. Therefore,
lifelong follow-up is recommended.
The risk of upper urinary tract recurrence increases in
patients with multiple and high-risk tumours.
Positive urine test results have a positive impact on the
quality of performed follow-up cystoscopy). It supports the
adjunctive role of urine tests during follow-up.
The following recommendations are only based on retrospective experience.
21
GUIDELINES ON UROTHELIAL
CARCINOMAS OF THE UPPER
URINARY TRACT (UTUCs)
(Text update April 2014)
Introduction
UTUCs are uncommon and account for only 5-10% of urothelial cell carcinomas. They have a similar morphology to bladder
carcinomas and nearly all UTUCs are urothelial in origin.
Classification
Table 1: TNM classification 2009 for renal pelvis and ureter
T - Primary Tumour
TX
Primary tumour cannot be assessed
T0
No evidence of primary tumour
Ta
Non-invasive papillary carcinoma
Tis
Carcinoma in situ
T1
Tumour invades subepithelial connective tissue
T2
Tumour invades muscularis
T3
(Renal pelvis) Tumour invades beyond muscularis
into peripelvic fat or renal parenchyma
(Ureter) Tumour invades beyond muscularis into
periureteric fat
T4
Tumour invades adjacent organs or through the
kidney into perinephric fat
N - Regional lymph Nodes
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Metastasis in a single lymph node 2 cm or less in the
greatest dimension
N2
Metastasis in a single lymph node more than 2 cm
but not more than 5 cm in the greatest dimension,
or multiple lymph nodes, none more than 5 cm in
greatest dimension
N3
Metastasis in a lymph node more than 5 cm in
greatest dimension
M - Distant Metastasis
M0
No distant metastasis
M1
Distant metastasis
Tumour grade
23
Diagnosis
GR
A
A
A
C
C
Prognostic factors
UTUCs that invade the muscle wall usually have a very poor
prognosis. Recognised prognostic factors in decreasing order
of importance include: tumour stage and grade; concomitant
carcinoma in situ (CIS); age; lymphovascular invasion; tumour
architecture; extensive tumour necrosis; molecular markers;
tumour location; and gender.
Risk stratification
It is necessary to risk stratify UTUC cases (i.e., with a functional contralateral kidney) before treatment to identify those
patients (and tumours) who are more suitable for conservative
treatment rather than radical extirpative surgery. Patients with
a normal contralateral kidney can be classified at the time of
24 Urothelial Carcinomas Of The Upper Urinary Tract
Management
GR
B
B
B
B
B
A
C
C
B
25
imperative cases (renal insufficiency, solitary functional kidney) or in selected elective cases (functional contralateral
kidney) for low-grade, low-stage tumours. The choice of
technique (ureteroscopy, segmental resection, percutaneous
access) depends on technical constraints, the anatomical
location of the tumour, and the experience of the surgeon.
Recommendations for the conservative management of
low-risk UTUCs
Indications
GR
Unifocal tumour
B
Small tumour (size < 1 cm)
B
Low-grade tumour (cytology or biopsies)
B
No evidence of an infiltrative lesion on CT urography
B
Understanding of close follow-up
B
Techniques
Laser should be used in the case of endoscopic
C
treatment
Flexible ureteroscopy is preferable over rigid
C
ureteroscopy
A percutaneous approach is an option for small, lowC
grade, caliceal tumours unsuitable for ureteroscopic
treatment
Ureteroureterostomy is indicated for non-invasive, low- C
grade tumours of the proximal ureter or mid-ureter that
cannot be removed completely by endoscopic means
Complete distal ureterectomy and neocystostomy is
C
indicated for non-invasive, low-grade tumours in
the distal ureter that cannot be removed completely by
endoscopic means and for high-grade, locally-invasive
tumours
The instillation of Bacillus Calmette-Gurin (BCG) or mitomycin C in the urinary tract by percutaneous nephrostomy or
via a ureteric stent is technically feasible after conservative
treatment of UTUCs. However, the benefits have not been
confirmed.
Advanced disease in UTUCs
RNU has no benefit in metastatic (M+) disease, but may be
used in palliative care. As UTUCs are urothelial tumours, platinum-based chemotherapy should give similar results to those
in bladder cancer. Currently, insufficient data are available to
provide any recommendations.
Radiotherapy is scarcely relevant nowadays both as a unique
therapy and associated with chemotherapy as a tumour adjuvant.
In all cases, there should be strict follow-up after radical management to detect metachronous bladder tumours, as well as
invasive tumours, local recurrence and distant metastases. In
conservative management, the ipsilateral upper urinary tract
requires careful follow-up due to the high risk of recurrence.
Recommendation for follow-up of UTUC after initial
treatment
After radical management, over at least 5 years
Non-invasive tumour
Cystoscopy/urinary cytology at 3 months and then
yearly
CT every year
Invasive tumour
Cystoscopy/urinary cytology at 3 months and then
yearly
GR
C
C
C
27
C
C
High-risk UTUC
Low-risk UTUC
Unifocal tumour
Size less than 1 cm
Low-grade
Non-invasive aspect on MDCT-urography
Conservative management:
ureteroscopy, segmental resection
Open
Laparoscopic
Recurrence
Close and stringent follow-up
Introduction
Staging system
29
31
Recommendations
Cystoscopy should describe all macroscopic features
of the tumour (site, size, number and appearance) and
mucosal abnormalities. A bladder diagram is
recommended.
Biopsy of the prostatic urethra is recommended for
cases of bladder neck tumour, when bladder CIS is
present or suspected, when there is positive cytology
without evidence of tumour in the bladder, or when
abnormalities of the prostatic urethra are visible.
If biopsy is not performed during the initial procedure,
it should be completed at the time of the second
resection.
In women undergoing a subsequent orthotopic neobladder, procedure information is required (including
a histological evaluation) of the bladder neck and urethral margin, either prior to, or at the time of
cystoscopy.
The pathological report should specify the grade, the
depth of tumour invasion and whether the lamina propria and muscle tissue are present in the specimen.
GR
C
GR
B
33
LE
3
3
3
3
3
3
3
2
35
A
B
B
Neoadjuvant chemotherapy
GR
A
37
Findings
pT2-4a, clinical N0M0 urothelial
carcinoma of the bladder
Neoadjuvant chemotherapy
Should be considered in selected
patients
5-7% 5 year survival benefit
Radical cystectomy
Know general aspects of surgery
o Preparation
o Surgical technique
o Integrated node dissection
o Urinary diversion
o Timing of surgery
A higher case load improves outcome
Recommendation
LE
TURB alone is not a curative treatment option in 2a
most patients.
GR
B
GR
A
Multimodality treatment
In a highly selected patient population, long-term survival
rates of multimodality treatment are comparable to those of
early cystectomy. Delay in surgical therapy can compromise
survival rates.
Recommendations
GR
Transurethral resection of bladder tumour alone can- B
not be offered as a standard curative treatment option
in most patients.
Radiotherapy alone is less effective than surgery and
B
is only recommended as a therapeutic option when
the patient is unfit for cystectomy or a multimodality
bladder-preserving approach.
Muscle-invasive and Metastatic Bladder Cancer
39
GR
B
Recommendation
Adjuvant chemotherapy should only be given within
clinical trials, whenever possible.
Adjuvant cisplatin-based combination chemotherapy
may be offered to patients with pN+ disease if no neoadjuvant chemotherapy has been given.
GR
A
C
Metastatic disease
Conclusions for metastatic disease
In a first-line setting, PS and the presence or absence
of visceral metastases are independent prognostic
factors for survival.
In a second-line setting, prognostic factors are: liver
metastasis, PS 1 and low haemoglobin (< 10 g/dL)
Cisplatin-containing combination chemotherapy can
achieve median survival of up to 14 months, with longterm disease-free survival reported in ~15% of patients
with nodal disease and good PS.
Single-agent chemotherapy provides low response
rates of usually short duration.
Carboplatin combination chemotherapy is less
effective than cisplatin-based chemotherapy in terms
of complete response and survival.
Non-platinum combination chemotherapy produces
substantial responses in first- and second-line
settings, but has not been tested against standard
chemotherapy in patients who are fit or unfit for
cisplatin combination chemotherapy.
There is no defined standard chemotherapy for unfit
patients with advanced or metastatic urothelial
cancer.
Vinflunine reached the highest level of evidence ever
reported for second-line use.
LE
1b
1b
1b
2a
2a
2a
2b
1b
41
GR
B
C
43
PS 2 or
GFR < 60mL/min
Comb. chemo:
Carbo-based
PS 2 and
GFR < 60mL/min
NO comb chemo
studies,
monotherapy, BSC
CISPLATIN?
yes
no
no
Second-line treatment
PS > 2
PS 0-1
2. Progression
> 6 -12 mo
after first-line
chemotherapy,
PS 0-1, impaired
renal function
a. vinflunine
b. clinical study
3. Progression
< 6 -12 mo
after first-line
chemotherapy,
PS 0-1
a. vinflunine
b. clinical study
Introduction
Screening
Prostate Cancer
45
Staging system
T2
T3
T4
46 Prostate Cancer
M - Distant Metastasis4
MX
M0
M1
47
48 Prostate Cancer
Other
If identified, presence of angio-invasion and/or intraductal
carcinoma
Location (site, zone) of dominant tumour (optional)
Perineural invasion (optional):
if present, specify extra- or intraprostatic location
LE
2a
GR
A
2b
2a
1b
1a
2b
Prostate Cancer
49
50 Prostate Cancer
LE
3
GR
A
2b
2b
Prostate Cancer
51
52 Prostate Cancer
LE
GR
2a
2a
2a
2a
1b
1a
GR
C
C
GR
B
Prostate Cancer
53
T1bT2b
T1aT2c
Hormonal
Combination
Active
surveillance
Not an option.
Not an option.
Treatment option in patients
with cT1c-cT2a, PSA
< 10 ng/mL, biopsy Gleason
score 6, 2 biopsies positive,
50% cancer involvement in
each biopsy.
Patients with a life expectancy > 10 years once they are
informed about the lack of survival data beyond 10 years.
Patients who do not accept
treatment-related complications.
Watchful
Patients with life expectancy <
waiting
10 years and Gleason score < 7.
Patients with life expectancy <
10 years and Gleason score = 7.
Radical
Optional in patients with pT1a
prostatectomy PCa.
Standard treatment for
patients with a life expectancy
> 10 years who accept treatment-related complications.
54 Prostate Cancer
A
C
B
A
B
A
Radiotherapy
Prostate Cancer
55
T3- T4 Watchful
waiting
Option in asymptomatic
C
patients with T3, Gleason
score 7, and a life expectancy
< 10 years who are unfit for
local treatment.
Radical
Optional for selected patients C
prostatectomy with T3a, PSA < 20 ng/mL,
biopsy Gleason score 8 and a
life expectancy > 10 years.
Patients have to be informed
that RP is associated with
an increased risk of positive
surgical margins, unfavourable
histology and positive lymph
nodes and that, therefore,
adjuvant or salvage therapy
such as radiation therapy or
androgen deprivation might be
indicated.
Radiotherapy T3 with > 5-10 years of life
A
expectancy. Dose escalation of
> 74 Gy seems to be of benefit.
A combination with hormonal
therapy can be recommended.
56 Prostate Cancer
Hormonal
N+,
M0
B
B
Prostate Cancer
57
Hormonal
Combination
M+
Watchful
waiting
B
B
Radical
C
prostatectomy
Radiotherapy Not an option for curative
C
intent; therapeutic option in
combination with androgen
deprivation for treatment of
local cancer-derived symptoms.
Hormonal
Standard option. Mandatory in A
symptomatic patients.
DT = doubling time; NHT = neoadjuvant hormonal treatment;
IPSS = International Prostatic Symptom Score;
PSA = prostate specific antigen; TRUS = transrectal ultrasound; TURP = transurethral resection of the prostate.
For more detailed information and discussion on second-line
therapy, please see the full text version of the guidelines.
58 Prostate Cancer
Prostate Cancer
59
60 Prostate Cancer
GR
A
A
An effort should be made to distinguish between the probability of local failure only, versus distant (+/- local) failure. Initial
pathology, how long after primary therapy the PSA-relapse
occurs and how fast the PSA-value is rising can all aid in the
distinction between local and distant failure. Poorly differentiated tumour, early PSA-relapse and a short PSA-doubling time
are all signs of distant failure. Treatment can then be guided
by the presumed site of failure, the patients general condition
and personal preferences. Imaging studies are of limited value
in patients with early PSA-relapse only.
Guidelines for imaging and second-line therapy LE
after treatment with curative intent
Biochemical failure (BCF) after RP
In case of BCF, bone scan and abdominopelvic
3
CT should be performed only in patients with a
PSA level > 10 ng/mL, or with high PSA kinetics
(PSA doubling time < 6 months or a PSA velocity
> 0.5 ng/mL/month) or in patients with symptoms of bone disease.
A choline PET/CT is not recommended in
3
patients with BCF and a PSA-level < 1 ng/mL.
GR
Prostate Cancer
61
tate-specific antigen doubling-time; RP = radical prostatectomy; RT = radiotherapy; SRP = salvage radical prostatectomy.
GR
Prostate Cancer
63
64 Prostate Cancer
Prostate Cancer
65
Docetaxel
Alpharadin
No visceral mets
Symptomatic patients
Docetaxel
Asymptomatic
Monitoring
Anti-androgens
Visceral mets
PS 2+
mCRPC
LE
GR
1b
2a
2a
2b
1b
Summary
67
Introduction
Staging system
The current UICC 2009 TNM (Tumour Node Metastasis) classification is recommended for the staging of RCC (Table 1).
Renal Cell Carcinoma
69
M - Distant metastasis
M0 No distant metastasis
M1 Distant metastasis
A help desk for specific questions about TNM classification is
available at http://www.uicc.org/tnm.
Histopathological classification
71
GR
B
B
C
C
C
C
C
The RCC types account for 85-90% of all renal tumours. The
remaining 10-15% include a variety of uncommon carcinomas,
a group of unclassified carcinomas, and several benign renal
tumour masses.
LE
3
GR
C
73
Nephron-sparing surgery
GR
B
B
or functional solitary kidney or bilateral RCC. Relative indications are a functioning opposite kidney affected by a condition
that might impair renal function and hereditary forms of RCC
with a high-risk of developing a tumour in the contralateral
kidney. Also localised unilateral RCC with a healthy contralateral kidney is an indication for nephron-sparing surgery since
recurrence-free and long-term survival rates are similar to
those for radical nephrectomy. Even in patients with a tumour
diameter of up to 7 cm, nephron-sparing surgery can achieve
results equivalent to those of a radical approach. If the tumour
is completely resected, the thickness of the surgical margin (> 1 mm) does not correlate with the likelihood of local
recurrence. If RCCs of larger size are treated with nephronsparing surgery, follow-up should be intensified, as there is an
increased risk of intrarenal recurrences.
75
Nephron-sparing surgery
Open
Laparoscopic/
Robot-assisted
Radical nephrectomy
Laparoscopic
T2
Radical nephrectomy
Open
Laparoscopic
Open
T3,T4
Nephron-sparing surgery
Radical nephrectomy
Open
Laparoscopic
Recommendations
Recommended
Recommended
Recommended standard only in patients not suitable for
nephron-sparing surgery
Optional in patients not suitable for nephron-sparing surgery
Recommended standard
Adequate and recommended, but carries a higher morbidity
Feasible in selected patients in experienced centres
Recommended standard
Feasible in selected patients
reduced morbidity, outpatient therapy, and the ability to treat
high-risk patients not fit for conventional surgery.
These experimental treatments might be used for selected
patients as in elderly and /or comorbid patients. The oncological efficacy remains to be determined for both cryotherapy
and radiofrequency ablation (RFA), which are the most frequently used minimally-invasive techniques. Data suggest
that for both treatments, tumour recurrence rates are higher
compared with nephron-sparing surgery.
77
GR
C
Adjuvant therapy
GR
A
GR
C
C
Chemotherapy
Chemotherapy as monotherapy is not considered effective in
patients with mRCC.
Immunotherapy
In general, interferon-alpha (IFN-) monotherapy is inferior to
targeted therapy in mRCC. IL-2 monotherapy may have a role
in selected cases (good PS, clear-cell type, lung metastases
only), since high-dose IL-2 is associated with durable complete
responses in a limited number of patients. However, IL-2 has
more side effects than IFN-. A combination of bevacizumab
and IFN- is more effective than IFN- in treatment-nave, lowrisk and intermediate-risk tumours.
No recommendations can be made at present for
vaccination therapy.
79
GR
A
Clear cell*
poor
temsirolimus
1b
Non-clear
cell
any
sunitinib
everolimus
temsirolimus
2a
2b
2b
Targeting agents
Novel agents for the treatment of mRCC include drugs
targeting VEGF, other receptor kinases and mammalian target
of rapamycin (mTOR). At present, several targeting drugs have
been approved both in the USA and in Europe for the
treatment of mRCC.
recommendations for systemic therapy in patients with
Second-line*
after VEGFR:
axitinib
sorafenib#
everolimus
after
cytokines:
sorafenib#
axitinib
pazopanib
any targeted
agent
any targeted
agent
LE^ Third-line*
2a
2a
2a
after VEGFR:
everolimus
after mTOR:
sorafenib
2a
1b
any
targeted
agent
LE
4
1b
2a
2a
81
GR
A
A
A
A
A
A
B
RN/PN/cryo/RFA
CT
CT
treatment for RCC taking into account patient risk profile and
2 years
US
CT
3 years
CT
US
4 years
US
CT
5 years
CT
CT
CT
CT
CT
CT
After 5 years
Discharge
CT alternate
2 years
CT alternate
years
83
GR
C
C
C
C
C
Introduction
Penile Cancer
85
pN1
pN2
87
Penile cancer can be cured in > 80% of cases but it is a lifethreatening disease with poor prognosis once metastatic
spread has occurred. Local treatment, although potentially
life-saving, can be mutilating and devastating for the
psychological well-being of the patient supporting the need
for careful diagnosis and adequate staging before any treatment decisions can be made.
Biopsy
In the management of penile cancer there is need for
histological confirmation if:
there is doubt about the exact nature of the lesion (e.g. CIS,
metastasis or melanoma) and/or;
treatment with topical agents, radiotherapy or laser surgery
is planned.
88 Penile Cancer
Penile Cancer
89
adenosquamous
carcinoma
<1
mucoepidermoid
carcinoma
clear cell
variant of
penile
carcinoma
<1
1-2
Physical Examination
Physical examination of a patient with penile cancer should
include palpation of the penis to examine the extent of local
invasion and careful examination of the groins for regional
lymph node enlargement.
Imaging
Ultrasound (US) can give information about infiltration of
the corpora.
Magnetic resonance imaging (MRI) in combination with
an artificial erection with prostaglandin E1 may be used
for excluding tumour invasion of the corpora cavernosa if
organ-preservation is planned and preoperative decisions
are needed.
In case of non-palpable inguinal nodes current imaging
techniques are not reliable in detecting micro-metastases.
A pelvic CT scan can be performed to assess pelvic lymph
nodes.
In case of positive inguinal nodes, CT of the abdomen and
pelvis and a chest X-ray are recommended; a thoracic CT
will be more sensitive than an X-ray.
90 Penile Cancer
GR
Treatment
Penile Cancer
91
92 Penile Cancer
Wide local excision plus reconstructive surgery, with or without skin grafting
Laser ablation with circumcision
Glansectomy with circumcision, with reconstruction
Radiotherapy by external beam
or brachytherapy for lesions
<4 cm in diameter
T2 with invasion Partial amputation and
of the corpora
reconstruction
cavernosa
Radiotherapy by external beam
or brachytherapy for lesions
<4 cm in diameter
T3 with invasion Partial penectomy or total
of the urethra
penectomy with perineal
urethrostomy
T4 with invasion Neoadjuvant chemotherapy
of other adjacent followed by surgery in
structures
responders
Alternative: palliative external
beam radiation.
Local recurrence Salvage surgery with penisafter conservasparing treatment in small
tive treatment
recurrences or partial
amputation.
C
Large or high stage recurrence: 3
partial or total amputation.
CO2 = carbon dioxide; Nd:YAG = neodymium:yttrium-aluminium-garnet.
Penile Cancer
93
The treatment of regional lymph nodes is crucial for the survival of the patient. A surveillance strategy carries considerable
risk as regional lymph node recurrence dramatically reduces
the chance of long-term survival. Invasive staging by modified
inguinal lymphadenectomy or dynamic sentinel node biopsy is
recommended for penile cancers pT1G2 and higher.
Guidelines for treatment strategies for nodal metastases
Regional
lymph nodes
LE
GR
2a
No palpable
inguinal
nodes (cN0)
94 Penile Cancer
LE
GR
2b
2a
Follow-up
Penile Cancer
95
Years 3-5
Amputation
1 year
3 months
6 months
6 months
3 months
1 year
3 months
6 months
Quality of life
96 Penile Cancer
Examinations and
investigations
Maximum duration
of follow-up
GR
Regular physician or
self-examination.
Repeat biopsy after topical or
laser treatment for CIS.
Regular physician or
self-examination.
5 years
5 years
5 years
5 years
5 years
Regular physician or
self-examination.
Regular physician or
self-examination.
US with FNAC optional
Regular physician or
self-examination.
US with FNAC optional
CT/MRI optional.
US = ultrasound.
97
Introduction
Compared with other types of cancer, testicular cancer is relatively rare accounting for approximately 1-1.5% of all
cancers in men.
A steady increase in incidence has been seen over the past
decades in the industrialised countries. The majority of these
tumours are derived from germ cells (seminoma and nonseminoma germ cell testicular cancer) and more than 70% of
patients are diagnosed with stage I disease. Nowadays testicular tumours show excellent cure rates, mainly due to early
diagnosis and their extreme chemo- and radiosensitivity.
Table 1: Prognostic risk factors for the development of
tumours
Epidemiological risk factors
History of cryptorchidism
Klinefelters syndrome
Familial history of testis cancer in first-grade relatives
Presence of contralateral tumour
Tin or infertility
98 Testicular Cancer
Classification
Testicular Cancer
99
Biopsy should be offered to patients with high risk for contralateral Tin (testicular volume < 12 mL, history of cryptorchidism
or poor spermatogenesis). If performed, a double biopsy is preferred. In case of Tin, local radiotherapy is is indicated
following counselling on impaired testosterone production
and infertility.
Staging system
Poor-prognosis group
Non-seminoma
(16% of cases)
5-year PFS 41%
5-year survival 48%
Mediastinal primary
Non-pulmonary visceral
metastases
AFP > 10,000 ng/mL or
hCG > 50,000 IU/L
(10,000 ng/mL) or
LDH > 10 x ULN
Seminoma
No patients classified as poor
prognosis
PFS = progression-free survival; AFP = alpha-fetoprotein;
hCG = beta-human chorionic gonadotrophin; LDH = lactate
dehydrogenase; ULN = upper limit of normal range.
uidelines for the diagnosis and staging of testicular
G
GR
cancer
Testicular US is mandatory.
A
Orchidectomy and pathological examination of the
A
testis is necessary to confirm the diagnosis and to
define the local extension (pT category). In a life-threatening situation due to extensive metastasis, chemotherapy has to be started before orchidectomy.
GR
A
B
A
A
GR
A
GR
A
Testicular Cancer
111
They are even rarer than Leydig cell tumours, and they are
malignant in 10-22% of cases. Morphological signs of
malignancy are:
Large size (> 5 cm);
Pleomorphic nuclei with nucleoli;
Increased mitotic activity;
Necrosis and vascular invasion.
They present either as an enlarged testis or as incidental ultrasound finding. Hormonal disorders are infrequent and serum
tumour markers are negative.
Ultrasonographically they generally appear as hypoechoic
and cannot be safely distinguished from germ-cell tumour
except for the subtype large cell calcifying form which is
usually associated with genetic syndromes (Carneys complex,
Peutz-Jeghers syndrome). Sertoli cell tumours are often interpreted as germ-cell tumours and an orchiectomy is
performed.
Organ-sparing surgery should be considered (with caution)
but in case of histological signs of malignancy orchiectomy
and RPLND are the treatment of choice.
Conclusions
Most testis tumours derive from germ cells and are diagnosed
at an early stage. Staging is the cornerstone and the 2009
114 Testicular Cancer
GUIDELINES ON NON-NEUROGENIC
MALE LUTS INCLUDING BENIGN
PROSTATIC OBSTRUCTION (BPO)
(Text update April 2014)
OAB detrusor
overactivity
Benign
Prostatic
Obstruction
(BPO)
And others
...
Distal
ureteral
stone
Nocturnal
polyuria
LUTS
Detrusor
underactivity
Bladder
tumour
Neurogenic
bladder
dysfunction
Urethral
stricture
Urinary
tract
infection
Prostatitis
Foreign
body
Assessment
The high prevalence and the underlying multifactorial pathophysiology mean an accurate assessment of LUTS is critical
to provide best evidence-based care. Clinical assessment of
LUTS aims to differentially diagnose and to define the clinical
profile. A practical algorithm has been developed (Figure 2).
LE
GR
A*
2b
A*
1b
A*
2b
No
Bothersome symptoms
Yes
Abnormal DRE
Suspicion of neurological
disease
High PSA
Abnormal urinalysis
Evaluate according to
relevant
Guidelines or clinical
standard
Significant PVR
US of kidneys
+/- Renal function
assessment
Medical treatment
according to treatment
algorithm
FVC in cases of
predominant storage
LUTS/nocturia
US assessment of
prostate
Uroflowmetry
Benign conditions of
bladder and/or prostate
with baseline values
PLAN TREATMENT
Surgical treatment
according to treatment
algorithm
Treatment
Conservative treatment
Watchful waiting is suitable for mild-to-moderate uncomplicated LUTS. It includes education, re-assurance, lifestyle
advice, and periodic monitoring.
Drug treatment
The level of evidence (LE) and the grade of recommendation
(GR) for each treatment option are summarized below.
LE
GR
1b
1b
1a
1b
1b
1b
no
Add Muscarinic
Receptor Antagonist
Residual
storage
symptoms
1-blocker
with or without
with or without
Watchful Waiting
no
5-Reductase Inhibitor
1-blocker/PDE5I
with or without
yes
Muscarinic Receptor
Antagonist
with or without
yes
prostate
volume
> 40 mL?
yes
storage symptoms
predominant?
no
long-term
treatment?
Nocturnal
polyuria
predominant
no
no
yes
bothersome
symptoms?
Male LUTS
with or without
Vasopressin Analogue
yes
Surgical treatment
LE
GR
1a
1a
1a
1a
1a
1b
1b
1a
1a
1a
1b
1b
1b
TUIP (1)
TURP
< 30 mL
TURP (1)
Laser enucleation
Laser
vaporization
TUMT
TUNA
30 - 80
mL
prostate
volume
low
Male LUTS
Open
prostatectomy (1)
HoLEP (1)
Laser
vaporization
TURP
> 80 mL
can stop
anti-coagulation?
yes
yes
High Risk
patients?
Laser
vaporization (1)
Laser
enucleation
no
can have
surgery under
anaesthesia?
high
TUMT
TUNA
Stent
no
Follow-up
GR
C
ERECTILE DYSFUNCTION
Definition, epidemiology and risk factors
Basic work-up
The basic work-up (minimal diagnostic evaluation) outlined in
Fig. 1 must be performed in every patient with ED.
Due to the potential cardiac risks associated with sexual
activity, the three Princeton Consensus Conference stratified
patients with ED wanting to initiate, or resume, sexual activity
into three risk categories. The low-risk group includes asymptomatic patients with less than three risk factors for coronary
artery disease (excluding male gender), mild or stable angina
(evaluated and/or being treated), uncomplicated past myocardial infarction, left ventricular dysfunction or congestive heart
failure (NYHA class I), post-successful coronary revascularisation, controlled hypertension, and mild valvular disease. All
other patients are included in an intermediate- or high-risk
category and require a cardiology consultation.
Specific examinations and tests
Although most patients with ED can be managed within the
sexual care setting, some circumstances require specific diagnostic testing:
Patients with primary erectile disorder (not caused by
organic disease or psychogenic disorder).
Young patients with a history of pelvic or perineal trauma
who could benefit from potentially curative vascular surgery.
Patients with penile deformities (e.g. Peyronies disease,
congenital curvature) that might require surgical correction.
Patients with complex psychiatric or psychosexual disorders.
Patients with complex endocrine disorders.
Specific tests may also be indicated at the request of the
patient or his partner.
Male Sexual Dysfunction 131
LE
3
GR
B
Treatment of ED
As a rule, ED can be treated successfully with current treatment options, but cannot be cured, with the exception of:
Psychogenic ED: psychosexual therapy may be given, either
alone or with another therapeutic approach, but takes time
and has had variable results.
Post-traumatic arteriogenic ED in young patients: surgical
penile revascularisation has a 60-70% long-term success
rate.
Hormonal causes of ED: testosterone replacement therapy
is effective, but should only be used after other endocrinological causes for testicular failure have been excluded.
Currently, it is contraindicated in men with untreated
prostate cancer, unstable cardiac disease and severe LUT
obstruction. Close follow-up is necessary, including digital
rectal examination (DRE), serum prostate-specific antigen
(PSA) and haematocrit assessment, as well as monitoring
the development of hepatic or prostatic disease.
Male Sexual Dysfunction 133
Identify
comon
causes of
ED
Identify
reversible
risk factors
for ED
Assess psychosocial
status
Penile
deformities
Prostatic
disease
Signs of
hypogonadism
Cardiovascular
and neurological
status
Laboratory tests
Glucose-lipid profile
(if not assessed in the
last 12 months)
Total testosterone
(morning sample).
If indicated, bio-available of
free testosterone
First-line therapy
Oral pharmacotherapy
Three potent, selective PDE5 inhibitors (PDE5Is) have been
approved by the European Medicines Agency (EMA) for the
treatment of ED. They are not initiators of erection and require
sexual stimulation for an erection to occur. Efficacy is defined
as rigidity sufficient for vaginal penetration.
Sildenafil (Viagra)
Sildenafil is effective following 30-60 min administration.
A heavy, fatty meal may reduce or prolong absorption. It is
administered in 25, 50 and 100 mg doses. The recommended
starting dose is 50 mg and adapted according to patient
response and side-effects. Efficacy may be maintained for
up to 12 h. Efficacy rates (erections sufficient for successful
intercourse) are 56%, 77% and 84% in men taking 25, 50 and
100 mg of sildenafil, respectively. The efficacy of sildenafil
in almost every subgroup of patients with ED has been well
established.
Tadalafil (Cialis)
Tadalafil is effective from 30 min after administration but its
peak efficacy occurs after about 2 h. Efficacy is maintained for
up to 36 h and is not affected by food. It is administered in 10
and 20 mg doses. The recommended starting dose is 10 mg
Male Sexual Dysfunction 135
ness, dyspepsia, and nasal congestion. Sildenafil and vardenafil have been associated with visual abnormalities in <2% of
patients, while tadalafil has been associated with back pain/
myalgia in 6% of patients. However, adverse events are generally mild in nature, self-limited by continuous use, and the
dropout rate due to adverse events is similar to placebo.
Cardiovascular safety
Clinical trials and post-marketing data of all PDE5Is have demonstrated no increase in myocardial infarction rates. No PDE5I
has adversely affected total exercise time or time to ischaemia
during exercise testing in men with stable angina. In fact, they
may improve exercise tests.
Nitrates are totally contraindicated with all PDE5Is due
to unpredictable hypotension. The duration of interaction
between organic nitrates and PDE5Is varies according to the
PDE5I and nitrate. If a patient develops angina while using a
PDE5I, other antiangina agents may be used instead of nitroglycerine or until after the appropriate time has passed (24 h
for sildenafil or vardenafil and 48 h for tadalafil).
In general, the adverse event profile of the PDE5I is not worsened, even when the patient is on multiple antihypertensive
agents.
Alpha-blocker interactions
All PDE5Is appear to interact with alpha-blockers, which
under some conditions may result in orthostatic hypotension.
Patients should be stable, on alpha-blocker therapy prior to
initiating combined treatment, and the lowest dose of PDE5Is
should be given initially.
Dosage adjustments
Lower doses of PDE5Is may be required in patients taking
Male Sexual Dysfunction 137
Second-line therapy
Patients not responding to oral drugs may be offered intracavernous injections. Alprostadil (Caverject, Edex/Viridal) is
the only drug approved for intracavernous treatment of ED. It
is the most efficacious monotherapy for intracavernous treatment using 5-40 g doses. The patient should be enrolled in
an office-based training programme (one or two visits) to learn
the correct injection process.
Complications of intracavernosal prostadil include penile pain
(50% of patients), prolonged erections (5%), priapism (1%),
and fibrosis (2%). Drug combinations (mainly the three-drug
combination of alprostadil + papaverine + phentolamine) may
increase efficacy by up to 90%. Fibrosis was found to be more
common (5-10%) if papaverine was used (depending on total
dose).
After 4 h of erection, patients are advised to consult their
doctor to avoid any damage to the intracavernous muscle, as
this will result in permanent impotence. Blood aspiration and
injection of phenylephrine are used to treat prolonged erections. If this problem occurs, the dosage of the next intracavernosal injection is usually reduced.
Prostaglandin E1 may be administered intra-urethrally as a
semi-solid pellet (125-1000 g). A band placed at the base of
the penis improves the resulting rigidity. The clinical success
rate is lower than with intracavernosal injections, but about
70% of patients are satisfied with treatment. Side-effects
include local pain (29-41%), dizziness (1.9-14%), and urethral
bleeding (5%).
Surgical implantation of a penile prosthesis may be considered in patients who fail pharmacotherapy or who want a
Male Sexual Dysfunction 139
LE
1a
GR
A
1b
1b
1a
1b
A
A
1b
4
B
C
Lifestyle changes
and risk factor
modification
Provide education
and counselling to
patients and partners
PDE5Is
Intracavernous injections
Vacuum devices
Intraurethral alprostadil
PREMATURE EJACULATION
LE
1a
GR
A
2a
Treatment of PE
such an indication.
Phosphodiesterase type 5 inhibitors
Several recent studies have supported the therapeutic role of
PDE5Is in PE. However, there is only one RCT comparing sildenafil to placebo. Although IELT was not significantly improved,
sildenafil increased confidence, the perception of ejaculatory
control and overall sexual satisfaction, reduced anxiety, and
decreased the refractory time to achieve a second erection
after ejaculation.
Guidelines on the treatment of PE
LE
Erectile dysfunction, other sexual dysfunction or 2a
genitourinary infection (e.g. prostatitis) should
be treated first.
Pharmacotherapy should be given as first-line
1a
treatment of lifelong PE.
Pharmacotherapy includes either dapoxetine
1a
on demand (a short-acting SSRI that is the only
approved pharmacological treatment for PE) or
other off-label antidepressants, i.e. daily SSRIs
and clomipramine, that are not amenable to ondemand dosing. With all antidepressant treatment for ED, recurrence is likely after treatment
cessation.
Off-label topical anaesthetic agents can be
1b
offered as a viable alternative to oral treatment
with SSRIs.
Behavioural and sexological therapies have a
3
role in the management of acquired PE. They are
most likely to be best used in combination with
pharmacological treatment.
ED = erectile dysfunction; PE = premature ejaculation;
SSRI = selective serotonin reuptake inhibitor.
146 Male Sexual Dysfunction
GR
B
A
A
Fig. 3: Management of PE
Clinical diagnosis of premature ejaculation based
on patient +/- partner history
Time to ejaculation (IELT)
Perceived degree of ejaculatory control
Degree of bother/distress
Onset and duration of PE
Psychosocial/relationship issues
Medical history
Physical examination
GUIDELINES ON
PRIAPISM
A. Salonia, I. Eardley, F. Giuliano, D. Hatzichristou, I. Moncada,
Y. Vardi, E. Wespes, K. Hatzimouratidis
Definition
Priapism is a pathological condition representing a true disorder of penile erection that persists beyond or is unrelated to
sexual interest or stimulation. Erections lasting up to 4 hours
are defined by consensus as prolonged. Priapism may occur
at all ages.
LE
1b
1b
2a
1a
2
3
Diagnosis
Priapism 151
GR
B
MANAGEMENT OF PRIAPISM
154 Priapism
GR
B
C
GR
B
156 Priapism
GR
B
GUIDELINES ON
PENILE CURVATURE
K. Hatzimouratidis (chair), I. Eardley, F. Giuliano, D. Hatzichristou,
I. Moncada, A. Salonia, Y. Vardi, E. Wespes
Peyronies disease
rate and operator-dependent and is not recommended in everyday clinical practice. Doppler US may be necessary to assess
vascular parameters.
Non-operative treatment
Conservative treatment of Peyronies disease is primarily
focused on patients in the early stages of disease. Several
options have been suggested, including oral pharmacotherapy
(vitamin E, potassium para-aminobenzoate, tamoxifen, colchicine, acetyl esters of carnitine, pentoxifylline), intralesional injection therapy (steroids, verapamil, clostridial collagenase, interferon) and other topical treatments (verapamil,
iontophoresis, extracorporeal shock wave therapy, traction
devices, vacuum devices).
The role of conservative treatment in men with stable/chronic
disease has not yet been adequately defined. No single drug
has been approved by the European Medical Association for
the treatment of Peyronies disease.
The results of the studies on conservative treatment for
Peyronies disease are often contradictory because of several
methodological problems that make it difficult to provide
recommendations in everyday real life.
Recommendations on non-operative treatment LE
for Peyronies disease
Conservative treatment for Peyronies disease is 3
primarily aimed at treating patients in the early
stages of disease. It is an option in patients not
fit for surgery or when surgery is not acceptable
to the patient.
GR
C
1b
1b
2b
1b
1b
1b
1b
1b
2b
Surgical treatment
Although conservative treatment for Peyronies disease should
resolve painful erections in most men, only a small percentage experience any significant straightening of the penis. The
aim of surgery is to correct curvature and allow satisfactory
intercourse. Surgery is indicated only in patients with stable
disease for at least 3 months, although a 6-12 month period
has also been suggested.
Two major types of repair may be considered for both congenital penile curvature and Peyronies disease: penile shortening
and penile lengthening procedures. Penile shortening procedures include the Nesbit wedge resection and the plication
techniques performed on the convex side of the penis. Penile
lengthening procedures are performed on the concave side
of the penis and require the use of a graft. They are used
to minimise penile shortening caused by Nesbit resection
or plication of the tunica albuginea or to correct complex
deformities. Several types of grafts include autologous grafts
(dermis, vein grafts, tunica albuginea, tunica vaginalis, temporalis fascia, buccal mucosa), allografts (cadaveric pericardium,
cadaveric fascia lata, cadaveric dura matter, cadaveric dermis), xenografts (porcine small intestine submucosa, bovine
pericardium, porcine dermis) and synthetic grafts (Gore-Tex,
Dacron). Finally, in patients with Peyronies disease and
erectile dysfunction not responding to medical treatments,
surgical correction of the curvature with concomitant penile
prosthesis implantation should be considered.
The decision on the most appropriate surgical procedure to
correct penile curvature is based on pre-operative assessment
of penile length, the degree of the curvature, and erectile function status. The results of the different surgical approaches
are presented in Table 1. It must be emphasised that there are
no randomised controlled trials available addressing surgery
162 Penile Curvature
LE
GR
2b
2b
2b
Active disease
(pain, deformity deterioration, no
calcification on US)
Stable disease
(no pain, no deformity deterioration,
calcification plaques on US)
Conservative treatment
Surgical treatment
No ED
Yes
Adequate penis length
Curvature < 60
Absence of special
deformities (hour-glass,
hinge)
Nesbit or plication
procedures
Short penis
Curvature > 60
Presence of special
deformities (hour-glass,
hinge)
Tunica lengthening
procedures
ED
Response
to
treatment
No
Penile
prosthesis
(remodelling,
plaque)
Definition
Infertility is the inability of a sexually active, non-contracepting couple to achieve spontaneous pregnancy in one year.
(WHO, 1995).
About 15% of couples do not achieve pregnancy within 1 year
and seek medical treatment for infertility. Eventually, less than
5% remain unwillingly childless.
Prognostic factors
Diagnosis
the male, since data show that in 1 out of 4 couples both male
and female partners have pathological findings.
Table 1: Reasons for a reduction in male fertility
Congenital factors (cryptorchidism and testicular
dysgenesis, congenital absence of the vas deferens)
Acquired urogenital abnormalities (obstructions, testicular
torsion, testicular tumour, orchitis)
Urogenital tract infections
Increased scrotal temperature (e.g. due to varicocele)
Endocrine disturbances
Genetic abnormalities
Immunological factors (autoimmune diseases, antisperm
antibodies)
Systemic diseases (diabetes, renal and liver insufficiency,
cancer, hemochromatosis)
Exogenous factors (medications, toxins, irradiation)
Lifestyle factors (obesity, smoking, drugs, anabolic steroids)
Idiopathic (40-50% of cases)
Semen analysis
Semen analysis forms the basis of decisions concerning further treatment. Analysis should be performed in a laboratory
adhering to national quality control standards (Table 2).
Table 2: Lower reference limits (5th centiles and 95%
confidence intervals) for semen characteristics*
Parameter
Lower reference
limit (95% CI)
Semen volume (mL)
1.5 (1.4-1.7)
39 (33-46)
Total sperm number (106 per ejaculate)
Sperm concentration (106 per mL)
15 (12-16)
Male Infertility 167
H
ypospermatogenesis - all cell types up to spermatozoa
are present, but there is a distinct decline in the number of
reproducing spermatogonia.
Treatment
Counselling
Lifestyle factors can impair semen quality, e.g. heavy smoking,
alcohol abuse, use of anabolic steroids, extreme sports (marathon training, excessive strength sports), and an increase in
scrotal temperature through thermal underwear, sauna or hot
tub use, or occupational exposure to heat sources. A considerable number of drugs can affect spermatogenesis.
Medical (hormonal) treatment
Antioxidant treatment (folic acid, vitamin E, zinc, selenium)
may have a positive influence on semen quality but infertile
couples should be advised that current evidence on their
benefit to promote pregnancy is inconclusive. No studies
have confirmed that hormonal therapies, such as human
menopausal gonadotrophin (HMG)/human chorionic gonadotrophin (HCG), androgen, anti-oestrogens (clomiphene and
tamoxifen), prolactin inhibitors (bromocriptine) and steroids,
have improved pregnancy rates in men with idiopathic OAT.
However, some primarily endocrinological pathologies can be
treated medically, including:
Low testosterone: clomiphene citrate 50 mg/day or
tamoxifen 20 mg/day;
Hypogonadotrophic hypogonadism: start HCG 1500 IU 3
times per week, and add HMG or FSH 75-150 IU 3 times per
week, until spermatogenesis occurs;
Hyperprolactinaemia: dopamine agonists.
In patients with anti-sperm antibodies, high-dose steroids are
not recommended because of serious side-effects and questionable benefit.
Male Infertility 173
Surgical treatment
Varicocele
The treatment of varicocele is a controversial subject, mainly
based on whether there is an actual need to treat varicocele
in infertile men. There is evidence of improved semen parameters after successful varicocele treatment. Current information supports the hypothesis that in some men, the presence
of varicocele is associated with progressive testicular damage
from adolescence onwards and consequent reduction in
fertility. Although treatment of varicocele in adolescents may
be effective, there is a significant risk of over-treatment. In
cases of normal semen analysis and in men with a subclinical varicocele, there appears to be no benefit from treatment
compared with observation. Varicocele repair, however, seems
effective in couples in whom the men has a oligo- or asthenozoospermia, a clinical varicocele, and otherwise unexplained
infertility.
Microsurgery/vasovasostomy and epididymovasostomy
Only urologists with experience in microsurgery should undertake these procedures using an operating microscope. The
likelihood of initiating pregnancy is inversely proportional to
the obstruction interval and becomes less than 50% after
8 years. Other important prognostic factors are the quality of the semen after the procedure and the partners age.
In approximately 15% of men who have undergone a successful vasovasostomy, sperm quality deteriorates to the
level of azoospermia or extreme oligospermia within 1 year.
Sometimes an epididymal obstruction coexists, especially
in men with a long interval between vasectomy and vasovasostomy. In these men a vaso-epididymostomy is indicated.
Considering that a vaso-epididymostomy has a limited effect
on pregnancy rates (20-30%), it is advisable to combine this
procedure with microsurgical epididymal sperm aspiration
(MESA), and cryopreserve the harvested spermatozoa for ICSI.
174 Male Infertility
GR
A
A
A
Men with severely damaged spermatogenesis (spermatozoa < 5 million/mL) should be advised to undergo
Yq microdeletion testing for both diagnostic and prognostic purposes. Yq microdeletion also has important
implications for genetic counselling (see below).
If complete AZFa or AZFb microdeletions are detected, micro-TESE is not necessary because it is extremely unlikely that any sperm will be found.
If a man with Yq microdeletion and his partner wish to
proceed with ICSI, they should be advised that microdeletions will be passed to sons, but not to daughters.
Standard karyotype analysis should be offered to all
men with damaged spermatogenesis
(spermatozoa <10 million/mL) who are seeking fertility
treatment by IVF.
Genetic counselling is mandatory in couples with a
genetic abnormality found in clinical or genetic investigation and in patients who carry a (potential) inheritable disease.
When a man has structural abnormalities of the vas
deferens (unilateral or bilateral absence), he and his
partner should be tested for CF gene mutations.
Aetiological treatments for ejaculatory disorders
should be offered before sperm collection and ART is
performed.
B
A
GUIDELINES ON
MALE HYPOGONADISM
G.R. Dohle (chair), S. Arver, C. Bettocchi, S. Kliesch, M. Punab,
W. de Ronde
Introduction
Male hypogonadism is a clinical syndrome caused by androgen deficiency. It may adversely affect multiple organ functions and quality of life. Androgens play a crucial role in the
development and maintenance of male reproductive and sexual functions. Low levels of circulating androgens can cause
disturbances in male sexual development, resulting in congenital abnormalities of the male reproductive tract. Later in life,
this may cause reduced fertility, sexual dysfunction, decreased
muscle formation and bone mineralisation, disturbances of fat
metabolism, and cognitive dysfunction. Testosterone levels
decrease as a process of ageing: signs and symptoms caused
by this decline can be considered a normal part of ageing.
However, low testosterone levels are also associated with several chronic diseases, and symptomatic patients may benefit
from testosterone treatment.
Androgen deficiency increases with age; an annual decline
in circulating testosterone of 0.4-2.0% has been reported. In
middle-aged men, the incidence was found to be 6%. It is more
prevalent in older men, in men with obesity, those with comorbidities, and in men with a poor health status.
Acquired forms
Pituitary tumour
(prolactinoma)
Drugs
Systemic disease (renal
failure, haemochromatosis,
hypothyroidism, trauma,
infections)
Abuse of anabolic steroids
Morbid obesity
Radiotherapy
Ageing
Obesity
Chronic diseases
Poor health status
Partial androgen insensitivity
syndrome (PAIS)
Diagnosis
Infertility
Low bone mass
Sarcopenia
Reduced sexual desire/activity
Table 3: Signs and symptoms associated with late-onset
hypogonadism
Loss of libido
Erectile dysfunction
Sarcopenia
Low bone mass
Depressive thoughts
Changes in mood, fatigue and anger
Sleep disturbances
Loss of body hair
Hot flushes
Loss of vigour
Insulin resistance
Metabolic syndrome
Visceral obesity
Gynaecomastia
Diminished cognitive functions
Routine screening for testosterone deficiency is not indicated.
However, testosterone assessment should be done in men
with:
Pituitary mass, following radiation involving the sellar
region and other diseases in the hypothalamic and sellar
region.
End-stage renal disease receiving haemodialysis.
Treatment with medications that cause suppression of testosterone levels e.g. corticosteroids and opiates;
Male Hypogonadism 181
Treatment
GR
C
B
A
Choice of treatment
Testosterone
undecanoate
Intramuscular;
Steady-state
one injection
testosterone
every 10-14 weeks levels without
fluctuation
Transdermal
testosterone
Gel or skin
patches; daily
application
Sublingual
testosterone
Sublingual; daily
doses
Buccal
testosterone
Buccal tablet;
two doses per
day
Subdermal
depots
Subdermal
implant every 5-7
months
Long-acting
preparation
that cannot
allow drug
withdrawal
in case of
onset of side
effects
Steady-state Skin irritation
testosterone at the site of
level without application
fluctuation
and risk of
interpersonal
transfer
Rapid absorp- Local irritation and
tion
achievement
of physiological serum
level of testosterone
Rapid absorp- Irritation and
tion and
pain at the
achievement site of appliof physiologi- cation
cal serum
level of testosterone
Long duration Risk of infecand constant tion and
serum testo- extrusion of
sterone level the implants
GR
A
C
ase reports and small cohort studies point to a possible
correlation between TRT and the onset of breast cancer,
but there is as yet a lack of strong evidence for this relationship.
Randomised controlled trials support the hypothesis
that TRT does not result in changes in prostatic histology.
However, there are not yet data available that show longterm prostatic safety of TRT.
Testosterone therapy is not related to the development
of de novo cardiovascular events. However, patients with
severe cardiovascular diseases should be screened first by
a cardiologist before TRT is initiated.
GR
A
GR
C
A
C
C
A
GUIDELINES ON URINARY
INCONTINENCE
(Text update April 2014)
This pocket version aims to synthesise the important clinical messages described in the full text and is presented as
a series of evidence summaries and graded action based
recommendations, which follow the standard for levels of evidence used by the EAU (see Introduction chapter).
Questionnaires
Recommendation
Use a validated and appropriate questionnaire when
standardised assessment is required.
* Recommendation based on expert opinion
GR
B*
Voiding diaries
Recommendations
GR
Ask patients to complete a voiding diary to evaluate
A
co-existing storage and voiding dysfunction in patients
with urinary incontinence.
Use a diary duration of between 3 and 7 days.
B
GR
A*
A
GR
A
B
C
B
A*
Urodynamics
Recommendations
GR
(NB: These refer only to neurologically intact adults
with urinary incontinence)
Clinicians carrying out urodynamics in patients with
C
urinary incontinence should:
Ensure that the test replicates the patients
symptoms
Interpret results in context of the clinical problem
Check recordings for quality control
Remember there may be physiological variability
within the same individual.
Advise patients that the results of urodynamics may
C
be useful in discussing treatment options, although
there is limited evidence that performing urodynamics
will predict the outcome of treatment for urinary
incontinence.
Urinary Incontinence 191
B
B
C
Pad testing
GR
C
C
Imaging
Recommendations
Do not routinely carry out imaging of the upper or
lower urinary tract as part of the assessment of
urinary incontinence.
Do not include bladder (detrusor) wall thickness
measurement in the routine assessment of urinary
incontinence.
192 Urinary Incontinence
GR
A
CONSERVATIVE MANAGEMENT
Adjustment of medication
GR
A
A
Constipation
GR
C
Lifestyle Changes
GR
A*
A*
A*
GR
A
B
GR
A
A
B
A
B
GR
C
B
GR
A
GR
C
Adrenergic drugs
Recommendation
GR
Offer mirabegron to people with urgency urinary
B
incontinence, but warn patients receiving mirabegron
that the possible long-term side effects remain uncertain.
Duloxetine
Recommendations
Duloxetine should not be offered to women or men
who are seeking a cure for their incontinence.
Duloxetine can be offered to women or men who
are seeking temporary improvement in incontinence
symptoms.
GR
A
B*
Oestrogen
Recommendations
Offer post-menopausal women with urinary incontinence vaginal oestrogen therapy particularly if other
symptoms of vulvovaginal atrophy are present.
Do not offer oral (systemic) oestrogen replacement
therapy as treatment for urinary incontinence.
Offer vaginal oestrogen therapy to post-menopausal
women with urinary incontinence, and vaginal atrophy.
Vaginal oestrogen therapy should be long-term and in
an appropriate dose.
GR
A
A
A
C
Desmopressin
Recommendations
GR
Offer desmopressin to patients requiring occasional
B
short-term relief from urinary incontinence and inform
them that this drug is not licensed for this indication.
Do not use desmopressin for long-term control of uri- A
nary incontinence.
GR
C
A*
B
SURGICAL TREATMENT
GR
A
Warn women who are being offered a retropubic insertion of midurethral sling about the relatively higher
risk of peri-operative complications compared to transobturator insertion.
Warn women who are being offered transobturator
insertion of mid-urethral sling about the higher risk of
pain and dyspareunia in the longer term.
Warn women who are being offered a single-incision
sling that long-term efficacy remains uncertain.
Do a cystoscopy as part of retropubic insertion of a
mid-urethral sling, or if difficulty is encountered during
transobturator sling insertion, or if there is a significant cystocoele.
Offer colposuspension (open or laparoscopic) or
autologous fascial sling to women with stress urinary
incontinence if mid-urethral sling cannot be considered.
Warn women undergoing autologous fascial sling that
there is a high risk of voiding difficulty and the need to
perform clean intermittent self-catheterisation; ensure
they are willing and able to do so.
Inform older women with stress urinary incontinence
about the increased risks associated with surgery,
including the lower probability of success.
Inform women that any vaginal surgery may have an
impact on sexual function.
Women who suffer from multiple risk factors should
be warned that they are less likely to have a successful
outcome from surgery for stress urinary incontinence.
Only offer new devices, for which there is no level 1
evidence base, as part of a structured research programme.
A
C
A*
GR
A
A
GR
A
C
A
A*
GR
A
GR
A
Cystoplasty/Urinary Diversion
Recommendations
Only offer augmentation cystoplasty to patients with
detrusor overactivity incontinence who have failed
conservative therapy, in whom the possibility of botulinum toxin and sacral nerve stimulation has been
discussed.
Warn patients undergoing augmentation cystoplasty
of the high risk of having to perform clean intermittent
self-catheterisation; ensure they are willing and able
to do so.
Do not offer detrusor myectomy as a treatment for
urinary incontinence.
GR
C
GR
C
A
GR
B
Urinary Fistula*
Recommendations
General
Surgeons undertaking complex pelvic surgery should
be competent at identifying, preserving and repairing
the ureter.
206 Urinary Incontinence
GR
C
B
C
C
C
B
Initial assessment
History
Physical examiniation
Questionnaire optional
Voiding dairy
Urinalysis
Post void residual
if voiding diculty
Pad test if quantication
of leakage is desired
C
A
A
C
B
A
Further
assessment
Haematuria
Pain
Recurrent UTI
Grade 3 or symptomatic prolapse
Previous pelvic radiotherapy
Previous surgery for UI
Pelvic mass
Suspicion of stula
Stress
incontinence
Consider P-PTNS
B
Anti-muscarinics
A
or mirabegron
B
C
A
A*
A
B
B
Urgency
incontinence
No response
individualised behavioural and physical therapies including pelvic floor muscle training
Discuss management
Stress
predominant
Failure
Offer MUS
A
Stress
incontinence
Mixed
incontinence
Urgency
incontinence
Advise onabotulinumtoxin A
or
sacral nerve stimulation
A
Urgency
predominant
Surgical treatment
in women
Initial assessment
History
Physical examiniation
Questionnaire optional
Voiding dairy
Urinalysis
Post void residual
if voiding diculty
Pad test if quantication
of leakage is desired
C
A
A
C
B
A
Further
assessment
Haematuria
Pain
Recurrent UTI
Previous pelvic radiotherapy
Abnormal DRE
Findings suspicious of voiding
dysfunction
Mixed
incontinence
Stress
incontinence
Consider P-PTNS
B
Anti-muscarinics
A
or mirabegron
B
C
A
A*
B
B
Urgency
incontinence
No response
individualised behavioural and physical therapies including pelvic floor muscle training
Mixed
incontinence
** Available evidence on
onabutulinumtoxinA and sacral nerve
stimulation refers mainly to women.
Stress
incontinence
Advise onabotulinumtoxin A
or
sacral nerve stimulation
A**
Urgency
predominant
Urgency
incontinence
Surgical treatment
in men with UI
GUIDELINES ON
UROLOGICAL INFECTIONS
(Text update April 2014)
Introduction
Diagnosis
UTI (general)
A disease history, physical examination and dipstick urine
analysis, including white and red blood cells and nitrite reacUrological Infections 217
Cystitis
acute,
sporadic and
uncomplicated
E. coli
Klebsiella
Proteus
Staphylococci
Pyelonephritis
acute,
uncomplicated
(usually febrile)
E. coli
Proteus
Klebsiella
Other enterobacteria
Staphylococci
UTI with
complicating
factors (febrile)
E. coli
Enterococci
Pseudomonas
Staphylococci
Nosocomial UTI
Klebsiella
Proteus
Pyelonephritis
severe
acute,
complicated
Enterobacter
Other enterobacteria
(Candida)
Therapy duration
Nitrofurantoin
Fosfomycin trometamol
Pivmecillinam
Alternative:
TMP-SMX1
Fluoroquinolone2,3
(5-)7 days
1 dose
(3-)5 days
Fluoroquinolone2
Cephalosporin (group 3a)
Alternatives:
Aminopenicillin/BLI
Aminoglycoside
7-10 days
Fluoroquinolone2
Aminopenicillin/BLI
Cephalosporin (group 2)
Cephalosporin (group 3a)
Aminoglycoside
3 days
(1-)3 days
Prostatitis
acute, chronic
Epididymitis
Ureaplasma:
Acute
Urosepsis
E. coli
Other enterobacteria
Pseudomonas
Enterococci
Chronic:
Staphylococci
Chlamydia
Ureaplasma
E. coli
Other enterobacteria
After urological
interventions - multiresistant pathogens:
Pseudomonas
Proteus
Serratia
Enterobacter
1Only
Fluoroquinolone2
Alternative in acute bacterial
prostatitis:
Cephalosporin (group 3a/b)
In case of Chlamydia or Ureaplasma:
Doxycycline
Macrolide
Cephalosporin (group 3a/b)
Fluoroquinolone2
Anti-Pseudomonas active
acylaminopenicillin/BLI
Carbapenem
Aminoglycoside
Acute:
2-4 weeks
Chronic:
4-6 weeks or
longer
Urethritis
Pyogenic urethritis is indicated by a Gram stain of secretion
or urethral smear that shows more than five leukocytes per
HPF (x1,000) and in case of gonorrhoea, gonococci are located
intracellularly as Gram-negative diplococci. A positive leukocyte esterase test or more than 10 leukocytes per HPF (x400)
in the first voiding urine specimen is diagnostic.
Prostatitis/CPPS
In patients with prostatitis-like symptoms, an attempt should
be made to differentiate between bacterial prostatitis and
CPPS. This is best done by the four glass test according to
Mearse & Stamey, if acute UTI and STD can be ruled out.
Urological Infections 221
For routine follow-up after uncomplicated UTI and pyelonephritis in women, dipstick urine analysis is sufficient.
In women with a recurrence of UTI within 2 weeks, repeated urinary culture with antimicrobial testing and urinary
tract evaluation is recommended.
In the elderly, newly developed recurrent UTI may warrant a
full evaluation of the urinary tract.
In men with UTI, a urological evaluation should be performed in adolescent patients, cases of recurrent infection and all cases of pyelonephritis. This recommendation
should also be followed in patients with prostatitis, epididymitis and orchitis.
In children, investigations are recommended after
two episodes of UTI in girls and one episode in boys.
Recommended investigations are ultrasound of the urinary
tract supplemented by voiding cystourethrography.
Urethritis
The following guidelines for therapy comply with the recommendations of the Center for Disease Control and Prevention
(2010). For the treatment of gonorrhoea, the following antimicrobials can be recommended:
First choice
Ceftriaxone 1 g im
as a single dose
(im with local anaesthetic)
Azithromycin 1g orally as
a single dose
Second choice
Ciprofloxacin 500 mg orally or
Ofloxacin 400 mg orally or
Levofloxacin 250 mg orally
as a single dose
First choice
Azithromycin
1 g (= 4 caps @ 250 mg)
orally as single dose
Doxycycline
2 times daily 100 mg orally
for 7 days
Second choice
Erythromycin
4 times daily 500 mg
orally for 7 days
Ofloxacin 2 times daily
300 mg orally or
Levofloxacin once daily
500 mg orally
for 7 days
Procedure
Pathogens
Prophylaxis
(expected)
(standard)
Diagnostic procedures
Transrectal biopsy of the
Enterobacteriaceae All patients
(Anaerobes)
prostate1
Cystoscopy
Enterobacteriaceae No
Urodynamic study
Enterococci
Staphylococci
Ureteroscopy
Enterobacteriaceae No
Enterococci
Staphylococci
Endourological surgery and SWL
SWL
Enterobacteriaceae No
Enterococci
Ureteroscopy for
Enterobacteriaceae No
uncomplicated distal stone Enterococci
Staphylococci
Ureteroscopy of proximal
Enterobacteriaceae All patients
or impacted stone and
Enterococci
percutaneous stone
Staphylococci
extraction
TUR of the prostate
Enterobacteriaceae All patients
Enterococci
prophylaxis in urology
Antibiotics
Remarks
Fluoroquinolones
TMP SMX
Metronidazole2
TMP SMX
Cephalosporin 2nd
generation
TMP SMX
Cephalosporin 2nd
generation
TMP SMX
Cephalosporin 2nd or
3rd generation
Aminopenicillin/BLI3
TMP SMX
Cephalosporin 2nd or
3rd generation
Aminopenicillin/BLI
TMP SMX
Cephalosporin 2nd or
3rd generation
Aminopenicillin/BLI
(Fluoroquinolones)
TMP SMX
Cephalosporin 2nd or
3rd generation
Aminopenicillin/BLI
No studies
Short course,
Length to be determined
Intravenous suggested at
operation
Low-risk patients and
small-size prostate
require no prophylaxis
TMP SMX
Cephalosporin 2nd or
3rd generation
Aminopenicillin/BLI
Consider in high-risk
patients.
Short post-operative
catheter requires no
treatment
TMP SMX
Cephalosporin 2nd or
3rd generation
Aminopenicillin/BLI
Single peri-operative
course
Cephalosporin 2nd or
3rd generation
Metronidazole
Cephalosporin 2nd or
3rd generation
Penicillin
(penicillinase stable)
without sulphamethoxale (co-trimoxazole); TUR = transurethral
GUIDELINES ON NEURO-UROLOGY
(Text update April 2014)
Introduction
Terminology
Classification
232 Neuro-Urology
Over-
active
Overactive
Over-
active
Over-
active
Underactive Normo-active
Urethral sphincter
Underactive
Overactive
Detrusor
Under-
active
Underactive
Under-
active
Normo-
active
Normo-active Overactive
Urethral sphincter
Normoactive
Underactive
234 Neuro-Urology
Fig. 2: The neurological status of a patient with neuro-urological symptoms must be described as completely as possible (a - dermatomes, b - associated reflexes)
Fig. 2a - Dermatomes of spinal cord levels L2-S4.
Urodynamic tests
Bladder diaries are considered a valuable diagnostic tool
in patients with neuro-urological disorders. A bladder diary
should be recorded for at least 2-3 days. Uroflowmetry and US
assessment of post-void residual should be repeated at least
2 or 3 times in patients able to void. Invasive urodynamic studies comprise mandatory assessment tools to determine the
exact type of neuro-urological disorder.
Recommendations for urodynamics and uro-neurophysiology
Recommendations
The recording of a bladder diary is advisable.
Non-invasive testing is mandatory before invasive
urodynamics is planned.
Urodynamic investigation is necessary to document
LUT (dys-) function and same session repeat measurement is crucial for clinical decision making.
Video-urodynamics is the gold standard for invasive
urodynamics in patients with neuro-urological symptoms. If this is not available, then a filling cystometry
continuing into a pressure flow study should be
performed.
A physiological filling rate and body-warm saline must
be used.
Specific uro-neurophysiological tests are elective procedures.
LUT = lower urinary tract.
GR
B
A
A
A
C
Filling phase
Increased, decreased, or absent bladder sensation
Vegetative non-specific sensations
Low bladder compliance
High capacity bladder
Detrusor overactivity, spontaneous or provoked
Incompetent urethral closure mechanism
Voiding phase
Acontractile or underactive detrusor
Bladder outlet obstruction
Detrusor Sphincter Dyssynergia (DSD)
Non-relaxing urethral sphincter obstruction
These signs warrant further neurological evaluation, as LUTD
may be the presenting symptom of a neurological disease.
*modified from ICS publication.
Recommendations for history taking and physical
examination
History taking
An extensive general history is mandatory, concentrating on past and present symptoms and conditions for
urinary, bowel, sexual, and neurological functions, and
on general conditions that might impair any of these.
Special attention should be paid to the possible existence of alarm signs, such as pain, infection, haematuria, fever, etc, that warrant further specific diagnosis.
A specific history should be taken for each of the four
mentioned functions.
Physical examination
Individual patient handicaps should be acknowledged
in planning further investigations.
GR*
Neuro-Urology 237
Treatment
LE
1a
GR
A
1b
1b
1a
Neuro-Urology 239
240 Neuro-Urology
GR
A
A
B
A
GR
A
A
B
LE
3
GR
A
LE
4
GR
A
2a
Neuro-Urology 241
LE
4
GR
A
Summary
GUIDELINES ON
UROLOGICAL TRAUMA
(Text update April 2014)
Introduction
Renal Trauma
Renal injuries (RI) account for 1-5% of all trauma and in 10% of
all abdominal trauma cases.
Table 1: Injury severity scale for the kidney*#
Grade Description
1
Contusion or non-expanding subcapsular
haematoma, no laceration
2
Non-expanding perirenal haematoma, cortical
laceration < 1 cm deep without extravasation
3
Cortical laceration > 1 cm without urinary
extravasation
4
Laceration: through corticomedullary junction
into collecting system or vascular: segmental renal
artery or vein injury with contained haematoma
5
Laceration: shattered kidney or vascular: renal
pedicle injury or avulsion
* Adapted from the American Association for the Surgery of
Trauma (AAST).
# Advance one grade for multiple injuries up to grade 3.
Diagnosis
H
aemodynamic stability should be assessed upon
admission.
History: time and setting of incident, past renal surgery,
known renal abnormalities.
Lab: gross haematuria, dipstick urine analysis, serial haematocrit, baseline serum creatinine.
In blunt trauma with macroscopic or microscopic
haematuria and hypotension, a history of rapid deceleration injury and/or significant associated injuries should
undergo radiographic evaluation.
Any degree of haematuria after penetrating abdominal or
thoracic injury requires urgent imaging.
Imaging: computed tomography (CT) scan, with and without intravenous contrast material, in haemodynamically
stable patients.
Ultrasound (US) may be helpful during the primary evaluation or follow-up of recuperating patients.
Angiography can be used for diagnosis and simultaneous
selective embolization of bleeding vessels if necessary.
Treatment
Observation,
bed rest,
serial Ht,
antibiotics
Observation
Grade 3
Angiography and
selective angioembolisation
Grade 1 2
Observation,
bed rest,
serial Ht, antibiotics
Vascular
Rapid deceleration
injury or major
associated injuries
Microscopic haematuria
Angiography and
selective angioembolisation
Grade 4 -5
Parenchymal
Contrast enhanced
spiral CT scan with
delayed images
Gross haematuria
Stable
Normal IVP
Renal exploration
(reconstruction or
nephrectomy)
Unstable
Observation
Observation,
bed rest, serial
Ht, antibiotics
Grade 1 2
Grade 4 -5
Unstable
Grade 3
Stable
Observation
Normal IVP
Renal exploration
(reconstruction or
nephrectomy)
Abnormal IVP,
Pulsatile or expanding
haematoma
R
epeat imaging is recommended in cases of suspected
complications,cases of fever, flank pain, or falling
haematocrit.
Nuclear scintigraphy is useful for documenting functional
recovery.
First follow up should be at approximately 3 months after
major renal injury with hospitalisation and should include:
physical examination, urinalysis, individualised radiological investigation, blood pressure measurement and serum
determination of renal function.
Long-term follow-up should be decided on a case-by-case
basis.
Complications following renal trauma require a thorough
radiographic evaluation.
Medical management and minimally invasive techniques
should be the first choice for the management of complications.
Ureteral Trauma
Diagnosis
A
high index of suspicion of ureteral injury should be maintained because the majority of cases are diagnosed late
and predispose the patient to pain, infection, and renal
function impairment.
Haematuria is an unreliable indicator.
Extravasation of contrast material in CT is the hallmark
sign of ureteral trauma, and in unclear cases, a retrograde
or antegrade urography is required for confirmation.
Treatment
P
artial injury can be managed with ureteral stenting or
urinary diversion by a nephrostomy.
In complete injuries, ureteral reconstruction following temporary urinary diversion is required.
The type of repair procedure depends on the site of the
injury (table 1), and it should follow the principles outlined
in table 2.
Proximal and mid-ureteral injuries can often be managed
by primary uretero-ureterostomy, while a distal injury is
often treated with ureteral reimplantation.
Mid ureter
Lower ureter
Complete
Reconstruction options
Uretero-ureterostomy
Transuretero-ureterostomy
Uretero-calycostomy
Uretero-ureterostomy
Transuretero-ureterostomy
Ureteral reimplantation and a Boari flap
Ureteral reimplantation
Ureteral reimplantation with a psoas hitch
Ileal interposition graft
Autotransplantation
Bladder Trauma
Diagnosis
Clinical signs and symptoms
External trauma
Cardinal sign: gross haematuria.
Others: abdominal tenderness, inability to void, bruises
over the suprapubic region, and abdominal distension (in
case of urinary ascites).
Penetrating bladder injury: entrance and exit wounds in
lower abdomen or perineum.
Bloody urethrorrhagia: suspect concomitant urethral injury.
Iatrogenic trauma
External perforation: extravasation of urine, visible laceration, clear fluid in the surgical field, appearance of the bladder catheter, and blood and/or gas (in case of laparoscopy)
in the urine bag.
Internal perforation: fatty tissue or bowel between detrusor
muscle fibres, inability to distend the bladder, low return of
irrigation fluid and/or abdominal distension.
Postoperative symptoms of unrecognised bladder perforation: haematuria, lower abdominal pain, abdominal
distension, ileus, peritonitis, sepsis, urine leakage from the
wound, decreased urinary output, and increased serum
creatinine.
Imaging
Treatment
Urethral Trauma
Diagnosis
B
lood at the external urethral meatus is the most common
clinical sign, and indicates the need for further diagnostic
work up.
Although non-specific, haematuria on a first voided specimen may indicate urethral injury. The amount of urethral
bleeding correlates poorly with the severity of injury.
Pain on urination or inability to void may indicate disruption.
Blood at the vaginal introitus is present in more than 80%
of female patients with pelvic fractures and co-existing urethral injuries.
Rectal examination may reveal a high riding prostate.
However, this is an unreliable finding. Blood on the examination finger is suggestive of a rectal injury associated with
pelvic fracture urethral bleeding or urinary extravasation
can cause penile and scrotal swelling and hematoma.
Retrograde urethrography is the gold standard for evaluating urethral injury and urethral catheterisation should be
avoided until the urethra is imaged.
In an unstable patient, however, an attempt can be made to
pass a urethral catheter (gently, by someone with urological experience). If this is not possible, a suprapubic cath254 Urological Trauma
Treatment
While intervention should be guided by the clinical circumstances, the following treatment is suggested:
Anterior urethral injuries are treated by primary urethral
repair only if associated with penile fracture or in penetrating wounds. Blunt trauma should be treated in the acute
management by suprapubic cystosomy or urethral catheterisation. After the patient has recovered from any associated injuries, and the urethral injury has stabilized, delayed
management is used after 3 to 6 months. Short and flimsy
strictures are managed by optical urethrotomy or urethral
dilatation. Denser strictures require urethral reconstruction.
Posterior urethral injuries are treated by primary open
repair only in stable patients with penetrating wounds. In
all other cases a suprapubic cystostomy is performed. In
stable patients with blunt trauma associated with complete urethral rupture an open surgery is only necessary
in the acute phase when complicated by bladder neck or
rectal injuries. In all other cases a suprapubic cystostomy is
the appropriate acute management.
If delayed management is conducted, it consists of
endoscopic realignment or delayed urethroplasty.
Urethral strictures following partial ruptures can be
treated by optical urethrotomy.
M
ost commonly caused by urethral instrumentation, and
results in stricture formation.
Due to their variable location and severity, they often
Urological Trauma 255
Genital Trauma
Diagnosis
U
rinalysis should be performed.
Macro- and or microhaematuria require a retrograde urethrogram in males, and consideration of cystoscopy in
females.
In women with genital injuries and blood at the vaginal
introitus, further gynaecologic investigation to exclude
vaginal injury.
In cases of suspected sexual abuse gynecological and
forensic support and advice is necessary and the emotional situation and privacy of the patient must be respected.
U
sually results from trauma to the erect penis during sexual intercourse or masturbation.
Penile Fracture
S
udden cracking or popping sound, pain and immediate
detumescence.
Local swelling of the penile shaft is seen and this may
extend to the lower abdominal wall.
The rupture of the tunica may be palpable.
256 Urological Trauma
T
horough history and examination confirms diagnosis
Imaging (US or magnetic resonance imaging [MRI]) may be
useful.
Treatment
S
ubcutaneous haematoma, without associated rupture of
the cavernosal tunica albuginea does not require surgical
intervention. Nonsteroidal analgesics and ice-packs are
recommended.
In penile fracture, early surgical intervention with closure of
the tunica albuginea is recommended.
Intra-operative flexible cystoscopy is useful to diagnose
urethral injury and to further localise tunical damage
Conservative management of penile fracture is not recommended.
R
arely seen in isolation.
Due to gunshot/knife injury, animal or human bites, assault
and industrial or self-inflicted mutilation.
Non-operative management is recommended in small
superficial injuries with intact Bucks fascia.
More significant injuries require surgical exploration and
debridement of necrotic tissue.
In extended injuries of the penis, primary alignment of
the disrupted tissues may allow for acceptable healing
because of the robust penile blood supply.
In avulsion of the penis, resuscitate the patient and
attempt re-implantation of the penis (if not too badly
damaged) - ideally microsurgical.
M
ay result in testicular dislocation, haematocoele, testicular rupture and/or scrotal haematoma.
Dislocation of the testicle is rare. Treat by manual replaceUrological Trauma 257
ment and secondary orchidopexy. If manual reposition cannot be performed, immediate orchidopexy is indicated.
If haematocele is smaller than three times the size of the
contralateral testis - conservative management.
If large haematocele - explore.
If testicular rupture suspected, explore, evacuate clot and
any necrotic testicular tubules and close the tunica albuginea.
S
urgical exploration with conservative debridement of nonviable tissue.
Primary reconstruction of testis and scrotum can be performed in most cases.
In complete disruption of the spermatic cord, realignment
without vaso-vasostomy may be considered.
In extensive destruction of the tunica albuginea, mobilisation of a free tunica vaginalis flap can be performed for
testicular closure.
If reconstruction cannot be achieved, orchiectomy is indicated.
In IED blast injury, the extensive loss of genital tissue often
requires complex and staged reconstructive surgical procedures.
Pain assessment using OPQRSTUV and physical assessment (pain area, pain type, pertinent history, risks of addiction, associated
symptoms-nausea, vomiting, constipation, dyspnoea, tingling, urinary retention)
In case of inadequate
pain control
Patient in opiod
treatment
Increase the
regular and
breakthrough
doses by 25%
Titrate dose every
24hrs
Make frequent
assessments and
opioid titration
until pain is
controlled.
If pain persists
iv access present
Opioid-nave patient
Morphine 5-10 mg
every 10 min until pain
is relieved
Patient on opioids
Give the usual per os
morphine dose iv every
10 min until pain is
relieved
No iv access present
Opioid-nave patient
Morphine 5-10 mg sc
every 20-30 min until
pain is relieved
Patient in opiod
treatment
Increase the regular
and breakthrough
doses by 25%.
Titrate dose every
24hrs.
Patient on opioids
Give the usual per
os morphine dose sc
every 20-30 min until
pain is relieved
Act accordinlgy
Drain, insert catheter
Stockings
Treat constipation or obstructive
ileus (if present)
Palliative hormonal therapy
Multiple painful
lesions
Consider radioisotopes
METASTASES
LOCAL
IMPAIRMENT
Prostate cancer
Start iv dexamethasone
8 mg/12 hours
SPINAL CORD
COMPRESSION
Consider radiotherapy
LOCAL
IMPAIRMENT
METASTASES
Single lesions
Multiple lesions
Consider single-fraction
radiotherapy
Local impairment
Ureteric obstruction
Invasion of surrounding areas
Soft tissue invasion
Nephroureterectomy
Consider extended operations (nephroureterectomy+bowel/
spleen/abdominal wall muscle resection) for selected cases of
advanced disease
Consider chemotherapy for locally advanced and/or metastatic
cancer
Bone metastases
Single lesions
Consider single-fraction
radiotherapy
Multiple lesions
LE
-
GR
GCP
1a
1b
Local impairment
Metastases
Ureteric obstruction
Invasion of surrounding areas
(posterior abdominal wall, nerve roots,
bowel, spleen, liver)
Soft tissue invasion
Bone
Nephrectomy
Consider extended operations (nephroureterectomy+bowel/
spleen/abdominal/wall muscle resection) for selected cases of
painful advanced disease
Consider radiotherapy
Consider radioisotopes
Brain
Consider radiosurgery
131
I-MIBG
Symptomatic treatment
Consider palliative
radiotherapy
Adrenocortical carcinoma
Symptomatic treatment
Consider palliative
radiotherapy
Adrenal carcinoma
Recommendations malignant phaeochromocytoma
131I-MIBG may reduce pain
Radiation therapy can induce partial remission
Recommendations adrenocortical carcinoma
Surgical removal of the primary tumour and
local lymph nodes can decrease pain
Radiotherapy can be effective for palliation and
pain management
LE
GR
2b
3
B
C
2b
Pain due to
lymphoedema
LE
2b
GR
B
Orchiectomy
GR
B
No pain
(SWL, transurethral,
percutaneous endoscopic,
transvaginal procedures)
P
aracetamol 500 mg-1g x 4 iv
and/or NSAIDs (diclofenac
50 mg x3 iv, ketorolac 10-30 mg
x 4 iv, lornoxicam 4-8 mg x 2 iv,
parecoxib 40 mg x 2 iv) and/or
metamizole 500-1000 mg x 4 iv
or paracetamol 500-1000 mg
plus codeine 30-60 mg x 4
orally.
P
aracetamol 500 mg-1g x 4 iv
and/or NSAIDs (diclofenac
50 mg x3 iv, ketorolac 10-30 mg
x 4 iv, lornoxicam 4-8 mg x 2 iv,
parecoxib 40 mg x 2 iv) and/or
metamizole 500-1000 mg x 4 iv
or paracetamol 500-1000 mg
plus codeine 30-60 mg x 4
orally.
Pethidine 50-100 mg x 6 iv or
tramadol 50-100 mg x 6 iv or
morphine 5 mg starting dose x
4-6 times per day sc/im or 2 mg
starting dose x 6 iv.
P
aracetamol 500 mg-1g x 4 iv
and/or NSAIDs (diclofenac
50 mg x3 iv, ketorolac 10-30 mg
x 4 iv, lornoxicam 4-8 mg x 2 iv,
parecoxib 40 mg x 2 iv) and/or
metamizole 500-1000 mg x 4 iv
PCA with morphine iv
(0.5-2.5 mg bolus, 10-15 min
lockout)
PCEA with morphine 100200g demand dose, lockout
interval 10-15 min and
continuous rate 300-600g/h
ropivacaine 0.2% 2 ml
demand dose, and continuous
rate 5 ml/h or bupivacaine
0.125% 2 ml demand dose and
continuous rate 4 ml/h.
GR
B
Transvaginal surgery
NSAIDs are often sufficiently effective after
2a
minor or moderate surgery.
NSAIDs decrease the need for opioids.
1b
Transperitoneal laparotomy
Consider continuous epidural infusion of a com- 1b
bination of opioids and local anaesthetic. Once
the patient is able to take oral analgesics use
metamizole, paracetamol codeine or tramadol.
Retroperitoneal approach - flank incision thoracoabdominal approach
Consider continuous epidural infusion of a com- 1b
bination of opioids and local anaesthetic. Once
the patient is able to take oral analgesics use
metamizole, paracetamol codeine or tramadol.
NSAIDs = non-steroidal anti-inflammatory drugs; PCA =
patient-controlled analgesia; PCEA = patient-controlled
epidural analgesia.
B
B
A
LE
1a
GR
A
2a
2a
1b
2a
B
B
1b
2a
1b
1a
1a
LE
GR
2b
2b
2b
2b
1b
Daily dose
Route of
administration
Conventional NSAIDs (non-selective COX inhibitors)
Ketorolac
10-30 mg four times daily Orally or iv
Ibuprofen
400 mg three times daily Orally
Ketoprofen
50 mg four times daily
Orally or iv
Diclofenac
75 mg twice daily
Orally or iv
50 mg three times daily
Orally or iv
100 mg twice daily
Rectally
COX-2 selective inhibitors
Meloxicam
15 mg once per day
Orally
Lornoxicam
4-8 mg twice daily
Orally or iv
Celecoxib
200 mg once per day
Orally
Parecoxib
40 mg once or twice daily iv form only
Etoricoxib
90-120 mg once daily
Orally
Method of
administration
Paracetamol Orally
Paracetamol iv
Metamizole
Metamizole
Orally
iv
Paracetamol Opioid
Paracetamol
1g
Paracetamol
600-650 mg
Paracetamol
500 mg
Paracetamol
300 mg
Paracetamol
650 mg
Codeine 60 mg
Times
per day
Four
Codeine 60 mg
Four
Codeine 30 mg
Four
Codeine 30 mg
Four
Dextropropoxyphene
65 mg
Paracetamol Tramadol 75-100
600-650 mg mg
Paracetamol Oxycodone 5 mg
325 mg
Four
Route of
administration
Orally or rectally
Orally or rectally
Orally or rectally
Orally or rectally
Orally
Four
Orally
Four
Orally
Method of
Common
administration single dose
(mg)
Tramadol
Orally
50
Tramadol
iv
50-100
Dihydrocodeine Orally
60-120
Piritramid
sc/im
15-30
Pethidine
Orally
25-150
Pethidine
Rectally
100
Pethidine
sc/im
25-150
Pethidine
iv
25-100
Morphine*
Orally
Starting
with 10
Maximal
dose (mg)
400-600
400-600
240
120
500
500
500
500
No maximal
dose
Morphine*
Rectally
Starting
No maximal
with 10
dose
Morphine*
sc/im
Starting
No maximal
with 5
dose
Morphine*
iv
Starting
No maximal
with 2
dose
Morphine*
Iv (PCA)
0.5-2.5 mg
No maximal
bolus
dose
10-15 min
lockout
*Strong opioids have no real upper dose limit (except
buprenorphine). The dose must be titrated in correlation
with pain relief and depending on the individual strength of
unwanted effects such as respiratory depression. A simple
way of calculating the daily dose of morphine for adults (20-75
years) is: 100 - patients age = morphine per day in mg.
PCA = patient-controlled analgesia.
Common equi-analgesic doses for parenteral and oral administration of opioids*
Drug
Parenteral (mg)
Oral (mg)
Morphine
10
30
Fentanyl
0.1
Pethidine
75
300
Oxycodone
15
20-30
Dextropropoxyphene 50
Tramadol
37.5
150
Codeine
130
200
*All listed opioid doses are equivalent to parenteral morphine
10 mg. The intrathecal opioid dose is 1/100, and
the epidural dose 1/10 of the dose required systemically.
PALLIATIVE CARE
Protocols for communicating with patients about major
topics in palliative care
Establishing goals
of medical care
Communicating
bad news
Withdrawing
treatment
Create the right setting: plan what to say, allow adequate time, and determine who else should be present at the meeting
LE
1a
GR
A
1b
1b
A
A
1b
1a
1a
1a
1b
1b
Agitated delirium
Haloperidol (5-10 mg, intravenous) can be useful 2a
Constipation
No clear recommendations as to the use of a
1a
particular laxative can be made.
Anxiety
It is therefore not possible to draw conclusions 4
about the effectiveness of pharmacotherapy in
this setting.
C
A
GR
A
B*
Causes
surgery
trauma
infection
Peripheral sensitisation
Abnormal peripheral
afferent signalling
Increased peripheral
afferent signalling
Central sensitisation
Abnormal central
afferent signalling
Abnormal central
efferent signalling
Abnormal central
processing
Consequences include:
sensory problems
Consequences include:
changes in organ function
History
Physical
examination
yes
Symptom of a well
known disease
Treat according to
specific disease
guidelines
no
no
Go to:
Pain management
(Alg. 2)
yes
urology
gynaecology
gastroenterology
neurology
sexology
pelvic floor
see
chapter 3
see
chapter 4
see
chapter 5
see
chapter 6
see
chapter 7
see
chapter 9
Holistic* approach
Sexology
Psychology
Physiotherapy
Pain medicine
See chapter 7
See chapter 8
See chapter 9
See chapter 10
*The term holistic means consideration of the complete person, physically, psychologically, socially, and spiritually, in the
management and prevention of disease.
Axis II
System
Axis III
End-organ as pain syndrome as identified
from Hx, Ex and Ix
Chronic Specific
pelvic
disease
pain
associated
pelvic pain
Urological
Prostate
Bladder
Scrotal
Testicular
Epididymal
Penile
Urethral
Postvasectomy
Vulvar
Vestibular
Clitoral
Endometriosis associated
CPPS with cyclical exacerbations
Dysmenorrhoea
Irritable bowel
Chronic anal
Intermittent chronic anal
Pudendal pain syndrome
Dyspareunia
Pelvic pain with sexual dysfunction
Any pelvic organ
OR
Pelvic pain
syndrome
Gynaecological
Gastrointestinal
Peripheral nerves
Sexological
Psychological
Musculo-skeletal
Axis IV
Axis V
Axis VI
Axis VII
Referral
Temporal
Character
Associated
character- characteristics
symptoms
istics
Suprapubic
ONSET
Aching
UROLOGICAL
Inguinal
Acute
Burning
Frequency
Urethral
Chronic
Stabbing
Nocturia
Penile/clitoral
Electric
Hesitance
Perineal
ONGOING
Dysfunctional flow
Rectal
Sporadic
Urge
Back
Cyclical
Incontinence
Buttocks
Continuous
Thighs
GYNAECOLOGICAL
TIME
Menstrual
Filling
Menopause
Emptying
Immediate post
GASTROINTESTINAL
Late post
Constipation
Diarrhoea
TRIGGER
Bloatedness
Provoked
Urge
Spontaneous
Incontinence
NEUROLOGICAL
Dysaesthesia
Hyperaesthesia
Allodynia
Hyperalegesie
Axis VIII
Psychological
symptoms
ANXIETY
About pain
or putative
cause of pain
Catastrophic
thinking about
pain
DEPRESSION
Attributed to
pain or impact
of pain
Attributed to
other causes
Unattributed
PTSD
SYMPTOMS
Re-experiencing
Avoidance
SEXUOLOGICAL
Satisfaction
Female dyspareunia
Sexual avoidance
Erectile dysfunction
Medication
MUSCLE
Function impairment
Fasciculation
CUTANEOUS
Trophic changes
Sensory changes
Assessment
Urology
Psychology
Organ
specific
Infection
Neurological
Tender
muscle
Palpation of the pelvic floor muscles, the abdominal muscles and the
gluteal muscles
GR
A
Treatment
Urine culture
Grade A
recommended
Uroflowmetry
Transrectal
US prostate
NIH-CPSI
scoring list
Grade B
recommended
Phenotyping
Electroacupuncture
Pelvic floor
muscle testing
Allopurinol
[B]
Pregabalin
[A]
[B]
US = Ultrasound
Biopsy
Not done
XX
1X
2X
3X
Normal
XA
1A
2A
3A
Inconclusive XB
1B
2B
3B
Positivec
XC
1C
2C
3C
aCystoscopy: glomerulations grade 23
bLesion per Falls definition with/without glomerulations
cHistology showing inflammatory infiltrates and/or detrusor
mastocytosis and/or granulation tissue and/or intrafascicular
fibrosis.
288 Chronic Pelvic Pain
GR
A
A
A
A
A
C
C
A
B
A
A
A
C
C
B
C
C
C
A
A
C
B
B
A
C
Administer submucosal injection of BTX-A plus hydrodistension if intravesical instillation therapies have
failed.
Intravesical therapy with Bacillus Calmette Gurin is
not recommended in BPS.
Intravesical therapy with clorpactin is not recommended in BPS.
Intravesical therapy with vanilloids is not recommended in BPS.
Bladder distension is not recommended as a treatment of BPS.
Electromotive drug administration might be considered before more invasive measures.
Consider transurethral resection (or coagulation or
laser) of bladder lesions, but in BPS type 3 C only.
Neuromodulation might be considered before more
invasive interventions.
Consider bladder training in patients with little pain.
Consider manual and physical therapy in first
approach.
Consider diet avoidance of triggering substances.
Accupuncture is not recommended.
Consider psychological therapy in multimodal
approach.
All ablative organ surgery should be last resort for
experienced and BPS knowledgeable surgeons only.
DMSO = dimethyl sulphoxide.
A
A
C
C
C
B
B
B
B
C
C
B
A
Treatment
Urine culture
Grade A
recommended
Uroflowmetry
Cystoscopy with
hydrodistension
Bladder biopsy
Grade B
recommended
Micturition diary
Pelvic floor
muscle testing
Phenotyping
ICSI score list
Psychological therapy
Not recommended
Other comments
yes
no
TUR / laser
Adequate:
Inadequate:
* Retreat when
necessary
* Start other
treatment
* Oral agents
* TENS
* Complementary
medicine
Inadequate relief:
* start Intravesical
therapy
Still inadequate response:
* Refer to specialist
pain management unit
GR
Start with general treatment options for chronic pelvic pain (see Chapter 10 full text).
Treatment
Semen culture
Grade A
recommended
Uroflowmetry
Ultrasound
scrotum
(see full text)
Pelvic floor
muscle testing
Phenotyping
Grade B
recommended
Grade C
recommended
Other
comments
GR
A
B
Treatment
Uroflowmetry
Grade A
recommended
Grade B
recommended
Micturition
diary
Pelvic floor
muscle testing
Phenotyping
Other comments
GR
A
B
B
B
C
Treatment
Gynaecological
examination
Grade A
recommended
Grade B
recommended
Ultrasound
Laparoscopy
(see text)
GR
A
A
B
B
C
C
Treatment
Endoscopy
Grade A
recommended
Biofeedback treatment
Grade B
recommended
Other comments
Pelvic floor
muscle testing
Anorectal
manometry
Rectal balloon
expulsion test
MRIdefecography
Electrogalvanic stimulation
Percutaneous tibial nerve stimulation
no
Tenderness of puborectalis
muscle
yes
no
* Anorectal manometry
* Balloon expulsion test
* MRI-Defecography
Anorectal pain
syndrome
Specific disease
guidelines
Dysfunction present
yes
no
Refer to specialist
pain management
unit
* Biofeedback
* Electro stimulation
* Physical therapy
* PTNS
* SNS
GR
A
B
Treatment
Extended
neurological
tests
Grade A
recommended
Grade B
recommended
Extended
history on
nature of pain
Standardised
questionnaires
GR
B
B
B
Treatment
History of
sexual
functioning
Grade A
recommended
Grade B
recommended
History of
negative
experiences
Ask about
abuse
Psychiatric
history
History of
relationship
GR
A
Treatment
Psychological
history
Grade A
recommended
Investigate
pain-related
beliefs and
behavior
Grade B
recommended
GR
A
B
B
A
Treatment
Palpation of
the muscles
Grade A
recommended
Testing of
pelvic floor
function
Pelvic floor
muscle EMG
Test for
myofascial
trigger points
Grade B
recommended
History of all
the involved
organs
Standardised
questionnaires
Other comments
Nerve blocks
Have a role as
part of a broad
management
plan
TENS
1b B
There is no
good evidence for or
against the
use of TENS.
Data covered
chronic pain
not just CPP
and was insufficient regarding long-term
treatment
effects.
Neuromodulation Pelvic pain
3
C
Role developing with
increasing
research.
NSAIDs = non-steroidal anti-inflammatory drugs;
TENS = transcutaneous electrical nerve stimulation.
Treatment
General
history
Grade A
recommended
Medications
used
Allergic
reactions
Use of alcohol
Daily activities
that will be
affected
Other comments
[C]
no
Simple analgesics
1. Amitriptyline
2. Gabapentin
Alternatives:
1. Nortriptyline or Imipramine
2. Pregabalin
Review
Review
Adequate
analgesia:
Inadequate
response:
Adequate
analgesia:
Inadequate
response:
review regularly
consider adding
another first line
agent
discharge back to
primary care
physician
refer to specialist
pain management
unit
sustained eect:
consider dose
reduction
rotate agents
Still inadequate:
refer to specialist
pain management
unit
GUIDELINES ON UROLITHIASIS
(Limited update April 2014)
Classification of stones
Radiolucent
Uric acid
Ammonium urate
Xanthine
2,8-dihydroxyadenine
Drug-stones
308 Urolithiasis
Urolithiasis 309
310 Urolithiasis
DIAGNOSIS
Diagnostic imaging
LE
4
GR
A*
LE
1a
GR
A
Urolithiasis 311
LE
3
GR
A*
Biochemical work-up
Recommendations
For sepsis with obstructing stones, the collecting system should be urgently decompressed,
using either percutaneous drainage or ureteral
stenting.
Definitive treatment of the stone should be
delayed until sepsis is resolved.
LE
1b
GR
A
1b
Stone relief
GR
A*
When deciding between active stone removal and conservative treatment using MET, it is important to consider the
individual circumstances of a patient that may affect treatment decisions.
314 Urolithiasis
GR
A
GR
A
C
A
Urolithiasis 315
LE
316 Urolithiasis
Oral chemolysis
GR
A
Urolithiasis 317
A
A
SWL
The success rate for SWL will depend on the efficacy of the
lithotripter and on:
size, location (ureteral, pelvic or calyceal), and composition
(hardness) of the stones;
patients habitus;
performance of SWL.
Contraindications of SWL
Contraindications to the use of SWL are few, but include:
pregnancy;
bleeding diatheses;
uncontrolled urinary tract infections (UTIs);
severe skeletal malformations and severe obesity, which
prevent targeting of the stone;
arterial aneurism in the vicinity of the stone;
anatomical obstruction distal of the stone.
Stenting prior to SWL
Kidney stones
A JJ stent reduces the risk of renal colic and obstruction, but
does not reduce formation of steinstrasse or infective complications.
Recommendation - stenting & SWL
LE
Routine stenting is not recommended as part of 1b
SWL treatment of ureteral stones.
SWL = shock wave lithotripsy.
318 Urolithiasis
GR
A
LE
1a
GR
A
Recommendation
In case of infected stones or bacteriuria,
antibiotics should be given prior to SWL.
SWL = shock wave lithotripsy.
LE
4
GR
C
GR
A*
GR
A*
LE
1b
GR
A
Ureterorenoscopy (URS)
GR
A*
Urolithiasis 321
Contraindications
Apart from general considerations, e.g. with general anaesthesia or untreated UTIs, URS can be performed in all patients
without any specific contraindications.
Access to the upper urinary tract
Most interventions are performed under general anaesthesia,
although local or spinal anaesthesia are possible. Intravenous
sedation with miniaturized instruments is especially suitable
for female patients with distal ureteral stones. Antegrade URS
is an option for large, impacted proximal ureteral calculi.
Safety aspects
Fluoroscopic equipment must be available in the operating
room. If ureteral access is not possible, the insertion of a
JJ stent followed by URS after a delay of 7-14 days offers an
appropriate alternative to dilatation.
Recommendation
Placement of a safety wire is recommended.
*Upgraded following panel consensus.
GR
A*
GR
A*
LE
1a
GR
A
1a
Open surgery
Morbid obesity
Skeletal deformity, contractures and fixed deformities of
hips and legs
Comorbidity
Concomitant open surgery
Non-functioning lower pole (partial nephrectomy), nonfunctioning kidney (nephrectomy)
Patient choice following failed minimally invasive procedures; the patient may prefer a single procedure and avoid
the risk of needing more than one PNL procedure
Stone in an ectopic kidney where percutaneous access
and SWL may be difficult or impossible
For the paediatric population, the same considerations
apply as for adults.
Laparoscopic surgery
324 Urolithiasis
Recommendations
Laparoscopic or open surgical stone removal
may be considered in rare cases where SWL,
URS, and percutaneous URS fail or are unlikely
to be successful.
When expertise is available, laparoscopic surgery should be the preferred option before proceeding to open surgery. An exception is complex renal stone burden and/or stone location.
For ureterolithotomy, laparoscopy is recommended for large impact stones or when endoscopic lithotripsy or SWL have failed.
LE
3
GR
C
Ureter:
stones with a low likelihood of spontaneous passage;
persistent pain despite adequate pain medication;
persistent obstruction;
renal insufficiency (renal failure, bilateral obstruction, single kidney).
Kidney:
stone growth;
stones in high-risk patients for stone formation;
obstruction caused by stones;
infection;
symptomatic stones (e.g. pain, haematuria);
stones > 15 mm;
stones < 15 mm if observation is not the option of choice;
patient preference (medical and social situation);
comorbidity;
choice of treatment.
The suspected stone composition might influence the choice
of treatment modality.
Urolithiasis 325
Recommendations
GR
For asymptomatic caliceal stones in general, active
C
surveillance with an annual follow-up of symptoms
and stone status (KUB, ultrasonography [US], NCCT)
is an option for 2-3 years, whereas intervention should
be considered after this period provided patients are
adequately informed.
Observation might be associated with a greater risk of
necessitating more invasive procedures.
STONE REMOVAL
Recommendations
Urine culture or urinary microscopy is mandatory
before any treatment is planned and urinary infection
should be treated ahead of stone removal.
In patient at high risk for complications (due to antithrombotic therapy) in the presence of an asymptomatic caliceal stone, active surveillance should be
offered.
Temporary discontinuation, or bridging of antithrombotic therapy in high-risk patients, should be decided
in consultation with the internist.
Antithrombotic therapy should be stopped before
stone removal after weighting the thrombotic risk.
If stone removal is essential and antithrombotic
therapy cannot be discontinued, retrograde (flexible)
ureterorenoscopy is the preferred approach since it is
associated with less morbidity.
*Upgraded based on panel consensus.
GR
A*
B
A*
Radiolucent uric acid stones, but not sodium urate or ammonium urate stones, can be dissolved by oral chemolysis.
326 Urolithiasis
> 20 mm
1. PNL
2. RIRS or SWL
10-20 mm
SWL or Endourology*
< 10 mm
1. SWL or RIRS
2. PNL
Yes
10-20 mm
SWL or Endourology
Favourable
factors for
SWL***
No
1. Endourology
2. SWL
First choice
Second choice
SWL
URS
URS (retrograde or antegrade)
or SWL
Distal ureter < 10 mm
URS or SWL
Distal ureter > 10 mm
URS
SWL
*Upgraded following panel consensus.
Recommendation
Percutaneous antegrade removal of proximal ureteral
stones is an alternative when SWL is not indicated
or has failed, and when the upper urinary tract is not
amenable to retrograde URS.
SWL = shock wave lithotripsy; URS =ureterorenoscopy.
GR
A
Steinstrasse
328 Urolithiasis
LE
1b
GR
A
Residual stones
Recommendations
LE
GR
Identification of biochemical risk factors and
1b
A
appropriate stone prevention is particularly
indicated in patients with residual fragments or
stones.
Patients with residual fragments or stones
4
C
should be followed up regularly to monitor disease course.
After SWL and URS, MET is recommended using 1a
A
an a-blocker to improve fragment clearance.
For well-disintegrated stone material in the
1a
B
lower calix, an inversion therapy with simultaneous mechanical percussion manoeuvre under
enforced diuresis may facilitate stone clearance.
SWL = shock wave lithotripsy; URS = ureterorenoscopy; MET =
medical expulsion therapy.
The indication for active stone removal and selection of the
procedure is based on the same criteria as for primary stone
treatment and also includes repeat SWL.
LE
1a
GR
A
A
Urolithiasis 329
330 Urolithiasis
Horseshoe kidneys
Stones in transplanted
kidneys
Stones formed in urinary
division
Urolithiasis 331
332 Urolithiasis
Urolithiasis 333
LE
2b
1b
GR
B
A
1b
1b
A
A
334 Urolithiasis
Alcaline Citrate
9-12 g/d
or
Sodium
Bicarbonate
1.5 g tid2,4
5-8 mmol/d2
> 5 mmol/d
Alcaline
Citrate
9-12 g/d
Hydrochlorothiazide
Initially 25 mg/d
Up to 50 mg/d
Pyridoxine
Initial 5 mg/kg/d
Up to 20 mg/kg/d
> 1 mmol/d
Hyperoxaluria
Hypercitraturia
> 8 mmol/d
Hypercalcuria
24 h urine collection
Basic evaluation
Alkaline Citrate
9-12 g/d
or
Sodium
Bicarbonate
1.5 g tid2
PLUS
Allopurinol
100 mg/d
> 4 mmol/d
Alkaline Citrate
9-12 g/d
PLUS
Allopurinol
100-300 mg/d4
Magnesium
200-400 mg/d3
< 3 mmol/d
Hypomagnesuria
Hyperuricosuria and
Hyperuricemia > 380 mol
Hyperuricosuria
Urolithiasis 335
336 Urolithiasis
Hydrochlorothiazide
initially 25 mg/d
up to 50 mg/d
Hypercalciuria
> 8 mmol/d
Exclude UTI
Adjust urinary pH
between 5.8 and 6.2 with
L-methionine
200-500 mg 3 times daily
Exclude RTA
Elevated calcium
exclude HPT
Exclude RTA
Hydrochlorothiazide
initially 25 mg/d
up to 50 mg/d
Hypercalciuria
> 8 mmol/d
Exclude HPT
Basic evaluation
Basic evaluation
Brushite stones
Carbonate apatite
stones
Calcium phosphate
stones
Hyperparathyroidism
Basic evaluation
Basic evaluation
Alcaline citrate
9-12 g/d2
Or
Sodium
bicarbonate
1.5 g tid
Allopurinol
100 mg/d
Dose depends on
targeted urine pH
Prevention
urine pH 6.2-6.8
Urine
pH > 6.5
Hyperuricosuria
Allopurinol
100-300 mg/d
UTI
Antibiotics
L-methionine
200-500 mg tid
Target urine-pH
5.8-6.2
Correction of
factors
predisposing
amm.urate stone
formation
Chemolytholisis
urine pH 6.5-7.2
Urolithiasis 337
Cystine stones
Basic evaluation
Appropriate hydration
with > 3.5 L/d in adults and
1.5 L/m2 body surface in
children
AND
Adjust urine pH
between 7.5. and 8.5
with
alkaline citrates or
sodium bicarbonate
Cystine excretion
< 3 mmol/d
Cystine excretion
> 3 mmol/d
338 Urolithiasis
LE
3,4
GR
A*
3
3
3
B
B
B
1b
LE
3
GR
B
Cystine stones
Therapeutic measures
Urine dilution
High fluid intake recommended so that 24-h urine
volume exceeds 3 L.
Intake should be 150 mL/h.
Alkalinisation
For cystine excretion < 3 mmol/day: potassium
citrate 310 mmol 2 or 3 times daily, to achieve
pH > 7.5.
Complex formation with cystine
For patients with cystine excretion > 3 mmol/day,
or when other measures are insufficient:
tiopronin, 2502000 mg/day.
Captopril, 75150 mg/day, remains a second-line
option if tiopronin is not feasible or unsuccessful.
Urolithiasis 339
Drug stones
Diagnostic imaging
Blood analysis
340 Urolithiasis
Urinalysis
GUIDELINES ON
RENAL TRANSPLANTATION
(Text update March 2009)
Introduction
Kidney donation
GR
C
Living donors
Organ donation should be considered a charitable gift.
Society can express gratitude to organ donors for their
gift (e.g. Medal of Honour, donor insurance).
Explore living donation when a patient first presents
with end-stage renal disease.
Decisions about multiple renal artery or grafts with
anatomical anomalies should be made on an individual
basis.
Laparoscopic nephrectomy offers similar results (complications, graft function and graft survival) compared
to open nephrectomy, with less post-operative morbidity, shorter convalescence and better cosmetic results.
Laparoscopic nephrectomy increases the number of
people willing to donate.
Paired kidney exchange, if permitted by national law.
C
C
C
C
infections of unknown aetiology, and a family history (or possible clinical signs) of Creutzfeldt-Jacob disease.
Different circumstances apply when a recipient is already
infected with HIV or hepatitis and transplant from infectious
donors is possible in certain situations.
A previous history of malignancy need not be a contraindication for organ donation. However, absolute contraindications
are active cancer, or a history of metastatic cancer (with a
few exceptions, e.g. testicular cancer), and cancers with high
recurrence rates, e.g. lymphoma. Exclude metastasis as a
cause of intracranial bleeding in a potential donor with a brain
haemorrhage of unknown aetiology. For special exceptions in
malignancy, consult the full Guidelines.
Kidneys from marginal donors must have a calculated creatinine clearance rate (CrCl) of 50-60 mL/min. Kidneys with CrCl
< 50 mL/min are only suitable for dual transplant.
Recommendations for brain dead donors
Consider every brain-dead comatose subject as a
potential organ donor, without age limits.
Obtain agreement for organ harvesting from relatives
(significant others) according to local law and policies.
Authorisation for explantation by the donors close
relatives is always recommended, even if local legislation presumes consent.
Always exclude individuals who objected to donation
during life.
A donor organ affected by a potentially transmissible
pathology (infections, neoplasias) must be carefully
evaluated considering the risk/benefits for the
recipient.
344 Renal Transplantation
GR
C
B
GR
B
B
Kidney recipient
GR
B/C
B/C
B/C
GR
B
C
B
B
C
GR
B
B
Kidneys from deceased donors should be allocated to recipients with the lowest number of HLA mismatches. Falsepositive results for cross-matching may occur especially in
autoimmune diseases. Potential recipients with a high percentage of panel-reactive antibodies (%PRA) can be further
analysed to ensure a negative cross-match. ABO blood group
matching prevents HAR, but technical advances have resulted
in successful ABO-incompatible transplantation.
GR
A
A
A
A
A
A
Complications
Annual screening
GUIDELINES ON
PAEDIATRIC UROLOGY
(Limited update April 2014)
Introduction
PHIMOSIS
Background
Treatment
Plastic circumcision (dorsal incision, partial circumcision) carries the potential for recurrence of the phimosis. Associated
frenulum breve is corrected by frenulotomy. Meatoplasty is
added if necessary. Childhood circumcision should not be recommended without a medical reason.
Circumcision: indication and contraindication
Contraindications for circumcision are coagulopathy, an acute
local infection and congenital anomalies of the penis, particularly hypospadias or buried penis, because the foreskin may be
required for a reconstructive procedure.
Conservative treatment
Agglutination of the foreskin does not respond to steroid
treatment.
Paraphimosis
It is characterised by retracted foreskin with the constrictive
ring localised at the level of the sulcus. A dorsal incision of the
constrictive ring may be required, or circumcision is carried
out immediately or in a second session.
CRYPTORCHIDISM
Diagnosis
Surgical treatment
Prognosis
LE
2
GR
A
1b
HYDROCELE
Background
Surgical treatment
HYPOSPADIAS
Background
Hypospadias are usually classified according to the anatomical location of the proximally displaced urethral orifice:
distal - anterior hypospadias (glanular, coronal or distal
penile);
intermediate - middle (penile);
proximal - posterior (penoscrotal, scrotal, perineal).
The pathology may be much more severe after skin release.
Assessment
Surgery
Outcome
Onlay, TIP
GAP, TIP, Mathieu,
MAGPI, advancement
Two-stage,
tube-onlay
Urethral plate
preserved
Urethral plate
cut
No chordee
Chordee
Proximal
Distal
Reconstruction required
Diagnosis at birth
Paediatric urologist
Exclude D.S.D.
No reconstruction
MICROPENIS
Surgical treatment
Ultrasound
investigation
Surgery:
Indication
Type
Conservative treatment:
Indication
Follow-up
Symmetrical testes
Normal spermiogram
(in older adolescents)
Measurement of testicular
size (during adolescence)
Repeated sperm analysis
(after adolescence)
Assessment
Monosymptomatic
Nocturnal enuresis
Education
Voiding diary or
direct questioning
Voiding habits
Wetting episodes
Bowel function
Urinalysis
Daytime wetting
Urge syndrome
Lower tract dysfunction
Infection
Other
Supportive therapy
Alarm or desmopressin
still wet
Uroflowmetry, urine V, Osm *
Check for night time polyuria
investigate for sleep disorders
Overactivity of the bladder
Surgical treatment
Surgical treatment comprises endoscopic injection of bulking
agents or ureteral reimplantation.
Subureteric infection of bulking agents: due to the availability
of biodegradable substances, endoscopic subureteric injection of bulking agents has become an alternative to long-term
antibiotic prophylaxis and surgical intervention.
Open surgical techniques: Overall, all surgical procedures offer
very high and similar success rates for correcting VUR.
Laparoscopy: a laparoscopic approach cannot be recommended as a routine procedure. It can be offered as an
alternative to the parents in centres where there is enough
experience.
Presentation
High
Symptomatic male
or female patients
after toilet-training
with high-grade reflux
(grades IV/V), abnormal
kidneys and LUTD
High
Symptomatic male or
female patients after
toilet-training with
high-grade reflux (grade
IV/V), abnormal kidneys
and no LUTD
Moderate Symptomatic male or
female patients before
toilet-training, with
high-grade reflux and
abnormal kidneys
Initial treatment
Initial treatment is
always for LUTD; intervention may be considered in cases of recurrent febrile infections
or persistent reflux
Intervention should be
considered
Follow-up
Greater possibility of earlier
intervention
Spontaneous resolution is
higher in males
Initial treatment is
always for LUTD.
Intervention may be
considered in cases
of breakthrough infections or persistent
reflux
Choice of treatment
is controversial.
Endoscopic treatment
may be an option.
LUTD treatment should
be given if needed.
Initial treatment is
always for LUTD
No treatment or CAP
No treatment or CAP in
infants
Disclaimer
The European Association of Urology (EAU) Clinical
Guidelines published by the EAU Guidelines Office are
systematically developed evidence statements incorporating data from a comprehensive literature review of the most
recent studies available (up to their publication date).
The aim of clinical guidelines is to help clinicians to make
informed decisions about their patients. However, adherence
to a guideline does not guarantee a successful outcome.
Ultimately, healthcare professionals must make their own
treatment decisions about care on a case-by-case basis, after
consultation with their patients, using their clinical judgement, knowledge and expertise. A guideline is not intended to
take the place of physician judgment in diagnosing and treatment of particular patients.
Guidelines may not be complete or accurate. The EAU and
their Guidelines Office, and members of their boards, officers
and employees disclaim all liability for the accuracy or completeness of a guideline, and disclaim all warranties, express
or implied to their incorrect use. Guidelines users always are
urged to seek out newer information that might impact the
diagnostic and treatment recommendations contained within
a guideline.
Due to their unique nature as international guidelines, the
EAU Guidelines are not embedded within one distinct healthcare setting - variations in clinical settings, resources, or common patient characteristics, are not accounted for.