PGI Callejas, Jeanette

R.S 71/M/M Brgy Balabag, Anilao, Iloilo

CC: TESTICULAR PAIN

History of Present Illness

1

day pta:
(+) testicular pain, on and off (+) hypogastric pain (+) blood in the urine (+) pain upon urination (-) fever (-) chills Immediately brought to this institution

Past Medical History

3 years pta: the patient was diagnosed to have BPH and was appraised for surgical operation, the patient refused. He was given unrecalled medications.

Personal/ Social History

(+) smoker 1 pack per day since 25 y.o (+) occasional alcoholic drinker

Scout Film
Gas & feces-filled nondilated loops. The flank stripes are intact. Renal & psoas shadows are partly obscured by the overlying bowel loops. There is an ovoid calcific density within the pelvis meas. 1.9 x 1.8 (LxW). There are osteophytic spurs in the lumbar area.

The right kidney meas. 13.5x 6.1 cm (LxW) while the left kidney meas,12.7x 7.0 cm. there is prompt opacification of both pelvocalyceal systems and the segmentally visualized ureters down to their respective ureteovesical junctions.

The minor calyces are well cupped. The major calyces are not dilated. The ureters are normal in size and within their normal anatomical course.

There is an outpouching in the posterolateral portion of the urinary bladder, meas. 2.4x 4.6 cm(LxW), a stalk app. meas 2.5 cm in length. There is also indentation in the posterior inferior portion of the urinary bladder.

Left Oblique

Post Void
Shows minimal retention of urine, there is persistence of the contrast filled outpouching.

Case Discussion

IVP

Used most widely for detection and diagnosis of the urinary tract It demonstrates the gross anatomic features of both the renal parenchyma and the urinary transport system.

Excretory Urogram

Provides important information about the functional capacity of the urinary system to make, transport and store urine.

Excretory Urogram

Scout film (AP)

Contrast medium is injected Ureteral compression is applied

The final film centered to demonstrate the bladder is exposed app. 20 mins after injection

Film centered and coned to demonstrate the kidneys, are exposed 5 and 10 mins after injection with the compression on.

After the 10 mins film, the compression device is released and a non compression film is exposed

Case Discussion
DIVERTICULA
Herniations of the bladder mucosa between interlacing muscle bundles. Most are located posterolaterally, near the ureterovesical junction May contain stones, tumor & occasionally do not fill on cystograms

Case Discussion

Acquired or congenital Acquired:

are outpouchings through a focal weakness in bladder muscle associated with chronically raised intravesical pressure. also arise through muscular defects in the bladder wall Majority are located paraureterally (Hutchs diverticulum)
often causes reflux.

Congenital:

Case Discussion
Most acquired are secondary to either obstruction to vesical neck or upper motor neuron type of neurogenic bladder intravesical pressure causes vesical mucosa to insinuate itself between hypertrophied muscle bundles, so that a mucosal extravesical sac develops

Case Discussion
Are rare in women Congenital: solitary & common among boys less than 10 years old Causes: (congenital) 1. congenital weakness at the level of ureterovesicular junction 2. aberrant voiding dynamics 3. anatomy

Case Discussion
Acquired: usually among males >60 Often multiple & commonly in lateral bladder walls Causes: 1. Bladder outlet obstruction 2. Neurogenic vesico-urethral dysfunction 3. Iatrogenic

Case Discussion
Large ones often displace the ureters & bladder Narrow neck ones likely urinary stasis, thus infection may follow Common presenting signs: 1. Recurring UTI 2. Hematuria (due to stone) 3. Passing of urine twice

Case Discussion
Metaplasia & tumor can occur with likelihood of spread beyond the bladder since it contains only urothelium without muscle. Can be evaluated with 1. cytogram 2. ultrasound 3. CT scan 4. cystoscopy

Case Discussion
Complications: 1.Urinary stasis 2.Infection 3.Stone formation 4.Vesicoureteral reflux 5.Bladder outlet obstruction

Case Discussion

Surgical Indications: 1. persistent/recurrent UTI 2. presence of stones in a diverticulum 3. tumor development in a diverticulum 4. lower urinary tract symptoms 5. voiding dysfunction 6. Vesico-ureteral reflux