Kidney Stones



Kidney stones are one of the most common disorders of the urinary tract. More than one million cases of kidney stones were diagnosed in 1985. It is estimated that ten percent of all people in the United States will have a kidney stone at some point in time. Men tend to be affected more frequently than women. Most kidney stones pass out of the body without any intervention by a physician. Cases that cause lasting symptoms or other complications may be treated by various techniques, most of which do not involve major surgery. Research advances also have led to a better understanding of the many factors that promote stone formation.

The Urinary Tract

The urinary tract, or system, consists of the kidneys, ureters, bladder, and urethra. The kidneys are two bean-shaped organs located below the ribs toward the middle of the back. The kidneys remove extra water and wastes from the blood, converting it to urine. They also keep a stable balance of salts and other substances in the blood. The kidneys produce hormones that help build strong bones and help form red blood cells. Narrow tubes called ureters carry urine from the kidneys to the bladder, a triangle-shaped chamber in the lower abdomen. Like a balloon, the bladder's elastic walls stretch and expand to store urine. They flatten together when urine is emptied through the urethra to outside the body.

What is a Kidney Stone?

A kidney stone develops from crystals that separate from urine and build up on the inner surfaces of the kidney. Normally, urine contains chemicals that prevent or inhibit the crystals from forming. These inhibitors do not seem to work for everyone, however, and some people form stones. If the crystals remain tiny enough, they will travel through the urinary tract and pass out of the body in the urine without even being noticed.

Kidney stones may contain various combinations of chemicals. The most common type of stone contains calcium in combination with either oxalate or phosphate. These chemicals are part of a person's normal diet and make up important parts of the body, such as bones and muscles.

A less common type of stone is caused by infection in the urinary tract. This type of stone is called a struvite or infection stone. Much less common are the uric acid stone and the rare cystine stone.

Urolithiasis is the medical term used to describe stones occurring in the urinary tract. Other frequently used terms are urinary tract stone disease and nephrolithiasis. Doctors also use terms that describe the location of the stone in the urinary tract. For example, a ureteral stone (or ureterolithiasis) is a kidney stone found in the ureter. To keep things simple, the term "kidney stones" is used throughout this entire document.

Gallstones and kidney stones are not related. They form in different areas of the body. If a person has a gallstone, he or she is not necessarily more likely to develop kidney stones.

Who Gets Kidney Stones?

For some unknown reason, the number of persons in the United States with kidney stones has been increasing over the past twenty years. White people are more prone to kidney stones than are black people. Although stones occur more frequently in men, the number of women who get kidney stones has been increasing over the past ten years, causing the ratio to change. Kidney stones strike most people between the ages of 20 and 40. Once a person gets more than one stone, he or she is more likely to develop others.

What Causes Kidney Stones?

Doctors do not always know what causes a stone to form. While certain foods may promote stone formation in people who are susceptible, scientists do not believe that eating any specific food causes stones to form in people who are not susceptible.

A person with a family history of kidney stones may be more likely to develop stones. Urinary tract infections, kidney disorders such as cystic kidney diseases, and metabolic disorders such as hyperparathyroidism are also linked to stone formation.

In addition, more than 70 percent of patients with acquired hereditary disease called renal tubular acidosis develop kidney stones.

Cystinuria and hyperoxaluria are two other rare inherited metabolic disorders that often cause kidney stones. In cystinuria, the kidneys produce too much of the amino acid cystine. Cystine does not dissolve in urine and can build up to form stones. With hyperoxaluria, the body produces too much of the salt oxalate. When there is more oxalate than can be dissolved in the urine, the crystals settle out and form stones.

Absorptive hypercalciuria occurs when the body absorbs too much calcium from food and empties the extra calcium into the urine. This high level of calcium in the urine causes crystals of calcium oxalate or calcium phosphate to form in the kidneys or urinary tract.

Other causes of kidney stones are hyperuricosuria (a disorder of uric acid metabolism), gout, excessive intake of vitamin D, and blockage of the urinary tact. Certain diuretics (water pills) or calcium-based antacids may increase the risk of forming kidney stones by increasing the amount of calcium in the urine.

Calcium oxalate stones may also form in people who have a chronic inflammation of the bowel or who have had an intestinal bypass operation, or ostomy surgery. As mentioned above, struvite stones can form in people who have had a urinary tract infection.

What Are the Symptoms?

Usually, the first symptom of a kidney stone is extreme pain. The pain often begins suddenly when a stone moves in the urinary tract, causing irritation or blockage. Typically, a person feels a sharp, cramping pain the back and side in the area of the kidney or in the lower abdomen. Sometimes nausea and vomiting occur with this pain. Later, the pain may spread to the groin.

If the stone is too large to pass easily, the pain continues as the muscles in the wall of the tiny ureter try to squeeze the stone along into the bladder. As a stone grows or moves, blood may be found in the urine. As the stone moves down the ureter closer to the bladder, a person may feel the need to urinate more often or feel a burning sensation during urination.

If fever and chills accompany any of these symptoms, an infection may be present. In this case, a doctor should be contacted immediately. How Are Kidney Stones Diagnosed?

Sometimes "silent" stones-those that do not cause symptoms-are found on x-rays taken during a general health exam. These stones would likely pass unnoticed.

More often, kidney stones are found on an x-ray, CT scan, or sonogram taken on someone who complains of blood in the urine or sudden pain. These diagnostic images give the doctor valuable information about the stone's size and location. Blood and urine tests help detect any abnormal substance that might promote stone formation.

The doctor may decide to scan the urinary system using a special x-ray test called an IVP (intravenous pyelogram) or CT scan. Together, the results from these tests help determine the proper treatment. IVP x-rays will miss some stones. CT scan will often call things stones that are not. Occasionally a patient will need both an IVP and CT scan or a repeat of the first test to confirm the presence of stones.

How Are Kidney Stones Treated?

Fortunately, most stones can be treated without surgery. Most kidney stones can pass through the urinary system with plenty of water (two to three quarts a day) to help move the stone along. In most cases, a person can stay home during this process, taking pain medicine as needed. The doctor usually asks the patient to save the passed stone(s) for testing.

The First Step: Prevention

People who have had more than one kidney stone are likely to form another. Therefore, prevention is very important. To prevent stones from forming, their cause must be determined. The urologist will order laboratory tests, including urine and blood tests. He or she will also ask about the patient's medical history, occupation and dietary habits. If a stone has been removed, or if the patient has passed a stone and saved it, the lab can analyze the stone to determine its composition.

A patient may be asked to collect his or her urine for 24 hours after a stone has passed or been removed. The sample is used to measure urine volume and levels of acidity, calcium, sodium, uric acid, oxalate, citrate, and creatinine (a byproduct of protein metabolism). The doctor will use this information to determine the cause of the stone. A second 24-hour urine collection may be needed to determine if the prescribed treatment is working.

Lifestyle Changes

A simple and most important lifestyle change to prevent stones is to drink more liquids -water is best. A recurrent stone former should try to drink enough liquids throughout the day to produce at least two quarts of urine in every 24-hour period.

Patients with too much calcium or oxalate in the urine may need to eat fewer foods containing calcium and oxalate. Not everyone will benefit from a low-calcium diet, however. Some patients who have high levels of oxalate in their urine may benefit from extra calcium in their diet. Patients may be told to avoid food with added vitamin D and certain types of antacids that have a calcium base.

Patients who have a very high level of acid in their urine may need to eat less meat, fish, and poultry. These foods increase the amount of acid in the urine.

To prevent cystine stones, patients should drink enough water each day to reduce the amount of cystine that escapes into the urine. This is difficult because more than a gallon of water may be needed every 24 hours, a third of which must be drunk during the night.

Medical Therapy

The doctor may prescribe certain medications to prevent calcium and uric acid stones. These drugs control the amount of acid or alkali in the urine, key factors in crystal formation. The drug allopurinol may also be useful in some cases of hypercalciuria and hyperuricosuria.

Another way a doctor may try to control hypercalciuria, and thus prevent calcium stones, is by prescribing certain diuretics, such as hydrochlorothiazide. These drugs decrease the amount of calcium released by the kidneys into the urine.

Some patients with absorptive hypercalciuria may be given the drug sodium cellulose phosphate. This drug binds calcium in the intestine and prevents it from leaking into the urine.

If cystine stones cannot be controlled by drinking more fluids, the doctor may prescribe the drug Thiola. This medication helps reduce the amount of cystine in the urine.

For struvite stones that have been totally removed, the first line of prevention is to keep the urine free of bacteria that can cause infection. The patient's urine will be tested on a regular basis to be sure that bacteria are not present. If struvite stones cannot be removed, the doctor may prescribe a new drug called aetohydroamic acid (AHA). AHA is used along with long-term antibiotic drugs to prevent the infection that leads to stone growth.

To prevent calcium stones that form in hyperparathyroid patients, a surgeon may remove all of the parathyroid glands (located in the neck). This is usually the treatment for hyperparathyroidism as well. In most cases, only one of the glands is enlarged. Removing the gland may end the patient's problem with kidney stones.

Surgical Treatment

Some type of surgery may be needed to remove a kidney stone if the stone:

* does not pass after a reasonable period of time and causes constant pain
* is too large to pass on its own
* blocks the urine flow
* causes ongoing urinary tract infection
* damages the kidney tissue or causes constant bleeding
* has grown larger (as seen on follow up x-ray studies).
Until recently, surgery to remove a stone was very painful and required a lengthy recovery time (four to six weeks). Today, treatment for these stones is greatly improved. Many options exist that do not require major surgery.

Extracorporeal Shockwave Lithotripsy

Lithotripsy
Extracorporeal Shockwave Lithotripsy (ESWL) is the most frequently used surgical procedure for the treatment of kidney stones. ESWL uses shockwaves that are created outside of the body to travel through the skin and body tissues until the waves hit the dense stones. The stones become sand-like and are easily passed through the urinary tract in the urine.

There are several types of ESWL devices. One device positions the patient in the water bath while the shock waves are transmitted. Other devices have a soft cushion or membrane on which the patient lies. Most devices use either x-rays or ultrasound to help the surgeon pinpoint the stone during treatment. For most types of ESWL procedures, some type of anesthesia is needed.

In some cases, ESWL may be done on an outpatient basis. Recovery time is short, and most people can resume normal activities in a few days.

Complications may occur with ESWL. Most patients have blood in the urine for a few days after treatment. Bruising and minor discomfort on the back or abdomen due to the shockwaves are also common. To reduce the chances of complications, doctors usually tell patients to avoid taking aspirin and other drugs that affect blood clotting for several weeks before treatment.

In addition, the shattered stone fragments may cause discomfort as they pass through the urinary tract in the urine. In some cases, the doctor will insert a small tube called a stent through the bladder into the ureter to help the fragments pass. Sometimes the stone is not completely shattered with one treatment and additional treatments may be required.

Percutaneous Nephrolithotomy

Sometimes a procedure called percutaneous nephrolithotomy is recommended to remove a stone. This treatment is often used when the stone is quite large or in a location that does not allow effective use of ESWL.

In this procedure, the surgeon makes a tiny incision in the back and creates a tunnel directly into the kidney. Using an instrument called a nephroscope, the stone is located and removed. For large stones, some type of energy probe (ultrasonic or electrohydraulic) may be needed to break the stone into small pieces. Generally, patients stay in the hospital for several days and may have a small tube called a nephrostomy tube left in the kidney during the healing process.

One advantage of percutaneous nephrolithotomy over ESWL is that the surgeon removes the stone fragments instead of relying on their natural passage from the kidney.

Ureteroscopic Stone Removal

Although some ureteral stones can be treated with ESWL, ureteroscopy may be needed for mid- and lower ureter stones. No incision is made in this procedure. Instead, the surgeon passes a small fiberoptic instrument called a ureteroscope through the urethra and bladder into the ureter. The surgeon then locates the stone and either removes it with a cage-like device or shatters it with a special instrument that produces a form of shockwave (EHL) or with a laser device. A small tube or stent may be left in the ureter for a few days after treatment to help the lining of the ureter heal.

Infertility



(Evaluation and Treatment of Male Infertility)

Infertility is currently a problem for one out of five couples presently trying to have children. If after a year of trying to conceive, a couple is not successful, a basic infertility evaluation may be started. However, if the female partner in the couple is over thirty or has a significant past medical history of irregular periods or previous pelvic infections, the infertility evaluation and tests can be started earlier.

Any couple embarking on an infertility work-up does so with some fear and reluctance. Some of the common concerns are: What is ahead? How painful is it? How expensive is it? And, What will the doctor find out? The whole world of doctors' offices, x-ray departments and hospitals is stressful for many people. It often helps to know what is ahead, to be informed and aware of how it will feel and what the doctor is hoping to find.

The infertility work-up itself follows a fairly specific sequence. A complete work-up or evaluation of the woman usually takes three or four cycles to complete. This is because certain tests have to be done at specific times in the menstrual cycle. The cost of a complete work-up can be as high as $3,000 if a laparoscopy is indicated. Insurance coverage varies. Some insurance plans do cover various tests relating to infertility; others do not.

The nature of the infertility work-up necessitates that it become a priority in your daily life. Suddenly, there are specific days that you must have intercourse. In certain tests you even have to report to the doctor's office a specific number of hours after intercourse. As a result, spontaneous lovemaking becomes difficult. Vacations and business trips become low priority. Schedules have to be made to fit the demands of the testing cycle. Many women find it hard to take time off from work, especially if they don't want it known that they are undergoing an infertility evaluation. It is a stressful time. Both husband and wife are being tested and scored. There is a feeling of "pass or fail" and a real sense of despair if a test comes back showing questionable or negative results. Women often feel frightened and violated by the infertility tests. Men often feel helpless. For the husband, testing is over if the semen analysis is normal. In contrast, he may see his wife having to go through various tests that can be painful and frightening. This understandably can upset both members of the couple. Added to this worry and uncertainty is the lingering fear of what the doctor will find. What if they indeed find an answer, but a discouraging one? Suffice it to say that deciding to start an infertility workup is a big decision.

The following is an overview of the tests involved. You may want to use it to understand what may be required medically or as a tool to double-check that you have had all the tests.

Initial Appointment

Some infertility specialists like to see the couple together for the first appointment. This provides an opportunity for the couple to establish good communication with the doctor. It also is an opportunity to evaluate what, if anything, has been done and what will be needed in the future. The doctor will be able to explain tests to the couple and will give them a time frame in which he or she hopes to complete the evaluation.

The doctor will take a very careful medical history from the male. He or she will also want to know about the medical history of the immediate family. Attention will be paid to details concerning previous surgery, infections, chronic illnesses, and hospitalizations. Background information on smoking, alcohol intake, medications, and exposure to environmental or occupational toxins will be requested. Of course, a reproductive history from both partners will be needed. Details about the types of birth control practiced will be obtained. In addition, any history of previous pregnancies should be discussed. Information about frequency and nature of sexual intercourse and previous venereal disease is crucial in the evaluation.

Physical Examination

A physical examination of the male is usually done on the first visit. The physical exam will include an examination of the genital organs, with the doctor noting size, position and condition of the penis and testes. A rectal exam is done to determine the size and consistency of the prostate gland and seminal vesicles. The doctor will also note the development of secondary sex characteristics. Again, routine blood and urine tests will be done.

Medical Evaluation of the Male

Semen Analysis - This is the first and most informative test done on the male. An analysis can be done any time because a man is not cyclic, as a woman is. Abstinence from intercourse for 48 hours before the analysis is suggested. Abstinence for a longer period than two days is not necessary. For the semen analysis, the doctor will ask the man to masturbate a specimen into a sterile container. This can be done at home and kept at body temperature and delivered to the lab for evaluation. Then the laboratory will examine the specimen under a microscope looking for the number of sperm present, how fast the sperm are swimming (motility) and the shape of the sperm (morphology). The doctor will also check the total volume of the specimen and its viscosity (thickness).

A fertile semen specimen should have at least 20 million sperm, with at least 50% of the sperm motile and 50-60% with good morphology. Normal volume is 2-5 cc. A semen analysis should be repeated at least once, because all of these levels fluctuate. It is also a good idea to repeat a semen analysis periodically if the infertility investigation of the couple is lengthy, as these levels can change over a long period of time.

If the semen analysis indicates that there may be an infertility problem, other tests on the semen will be done. The semen will be checked for the presence of fructose, a special kind of sugar produced in the epididymis. If it is absent, this may mean there is a blockage in the ductal system but that sperm production may be normal. In addition, the semen may be checked for unusual clumping or agglutination that could indicate an immunologic response, or a so-called sperm antibody condition. Some physicians also order a new test called the "zona free hamster egg test" to check that the sperm are, in fact, able to penetrate the outer layer of the hamster egg, which is very similar in structure to a human egg.

Several additional tests may be done on the male if the semen analysis is not normal:

1. Evaluation for a varicocele is done by palpating the scrotum while the man is bearing down or coughing. The link between the presence of a varicocele and infertility is not clearly understood. The most common theory is that the presence of a varicocele causes poor circulation, which ultimately inhibits normal sperm production.

2. In the event of a subfertile semen analysis, a small biopsy of both testicles may be done. This procedure is done in a hospital under local or general anesthesia. The testicular tissue is examined in the laboratory. This test can tell the doctor if there is an absolute infertile state with no sperm-producing tissue present, or blockage in the vas deferens indicated by the presence of normal testicular tissue yet little or no sperm in the ejaculate.

3. Finally, if a blockage in the vas deferens is suspected during a testicular biopsy, a vasography can be done to pinpoint the area of the blockage. This is an x-ray study in which dye is injected into the vas deferens and a series of x-rays are taken.

Once an infertility work-up is underway it is important that the couple get the results of each test as they are done. Couples should ask their doctors for explanations if need be. It is your body and you have a right to know what is being discovered. Sometimes it is wise to make a consultation appointment with your doctor if you feel confused or upset about the tests end results. This is especially important if the work-up has been going on for a long time or if there is a male factor problem as well as a female one, which is being treated by another doctor. It is easy to feel helpless and powerless during an infertility work-up. Good communication with your doctor can help alleviate some of these feelings

Urinary tract



(Urinary Tract Infection) What is the Urinary Tract?

The urinary tract makes and stores urine, one of your body's liquid waste products. The kidneys produce 1.5 to 2 quarts of urine every day by removing waste and water from the blood. The urine travels from the kidneys down two narrow tubes, called ureters. It is then stored in a balloon-like container called the bladder.

In an adult, the bladder can hold 10 to 20 ounces of urine (about as much liquid as in one can of soda). When the bladder is about half full, you may begin to feel the need to empty it by urinating. Urine is carried out of the body through the urethra, a tube that begins at the bottom of the bladder. The end of the urethra is near the top of the vagina in women. In men the urethra passes through the prostate gland and exits at the tip of the penis.

Normal urine contains no bacteria (sometimes referred to as "germs"), but bacteria do cover your skin and are present in large numbers in the rectal area and in your bowel movements. Bacteria may, at times, get into the urinary tract (and the urine) and may travel up the urethra into the bladder. When this happens, the bacteria cause infection and inflammation of the bladder. In other words, they multiply, causing irritation, swelling, and pain. Bladder infection, also called cystitis, is the most common urinary tract infection.

If the bacteria travel upward from the bladder through the ureters and reach the kidneys, you may develop a kidney infection, also known as pyelonephritis. Kidney infections are much less common but often more serious than bladder infections. What are the Signs of a Urinary Tract Infection?

When you have a urinary tract infection, the lining of the bladder and urethra becomes irritated just as the inside of your nose or throat does when you have a cold. The irritation can cause pain in your abdomen and pelvic area and may make you feel the need to constantly empty your bladder.

Your need to urinate may seem urgent; but when you try to do so, you may produce only a few drops of urine. In addition, you may feel a burning sensation as the urine comes out. It may even be hard to control; in fact, some urine may leak onto your clothing. You may notice that the urine has an unpleasant odor or a cloudy look. At times, bladder infections may also cause low back pain, fever, or chills.

Kidney infections produce fever and back pain much more commonly than do bladder infections. If a kidney infection is not treated promptly, the bacteria may spread to the bloodstream and cause a life-threatening infection.

In an infant or young child, the signs of a urinary tract infection may not be clear, especially if the child is too young to tell you just how he or she feels. Instead, the child may be irritable, not eat as much as usual, have a fever or loose bowel movements, or just not seem healthy. If the symptoms last more than a day, they may signal the need to see a doctor.

How do you Find Out Whether you Have a Urinary Tract Infection?

Only by consulting a doctor can you find out for certain whether you or your child has a urinary tract infection. If you think that such an infection might be present, check with your doctor. If you see blood in the urine, you should see your doctor right away. Because bloody urine is not normally caused by an infection, it may mean that you have a different urinary tract problem.

Your doctor will try to find out whether you have a urinary tract infection by examining samples of your urine under a microscope. If an infection is present, the physician may also perform a urine culture, a process in which bacteria from infected urine are grown in a laboratory. The germs can then be identified and tested to see which drugs will provide the most effective treatment. It often takes a day or two, however, to complete this testing.

How are these Infections Treated?

Urinary tract infections are treated with antibiotics (infection-fighting drugs), which are generally taken by mouth. Your doctor will choose a drug that treats the bacteria most likely to be causing your infection. Once the test results are in, however, the physician may switch you to another antibiotic, one that is more effective against the particular bacteria found in your urine.

The number of days you must take medication and the number of doses you must take each day depend, in part, on the type of infection you have and how severe it is. You will usually have to take the medicine for at least two to three days and possibly for as long as several weeks. The daily treatment schedule your doctor recommends depends on the specific drug prescribed. It may call for a single dose each day or up to four daily doses.

A few doses of the antibiotic may relieve you of the need to urinate often and most of the pain from a bladder infection. It may be several days, however, before the bladder infection and its symptoms vanish completely. In any case, it is important to take medications as prescribed by your doctor and not to stop them simply because the symptoms have gone away. Unless urinary tract infections are fully treated, they frequently return.

When you have a urinary tract infection, you should drink fluids whenever you are thirsty. It is not necessary to drink large amounts, but you should make certain that your body has the liquid it needs.

If the urinary tract infection is severe, it may involve the kidneys. In that case, antibiotic drugs may have to be injected. Hospital treatment with medication given intravenously (injected directly into the bloodstream) is sometimes necessary.

Facts about Urinary Tract Infections:

* Every year, 8 to 10 million visits to doctors occur because of urinary tract infections.
* The bacteria that cause urinary tract infections are treated with bacteria-fighting drugs called antibiotics.
* Women are usually more prone to urinary tract infections than men or children are.
* One to two percent of children develop urinary tract infections.
* Young children have the greatest risk for kidney damage due to urinary tract infections.
* Certain people who get one or more urinary tract infections may need further testing to make sure that they do not have other health problems.

Why Do you Get a Urinary Tract Infection?

Some people, mainly women, develop urinary tract infections because they are prone to such infections the way other people are prone to getting coughs or colds. Urinary tract infections are much less common in men and children than in adult women.

A number of factors may increase a person's risk of getting a urinary tract infection. Some of these factors include:

* having certain diseases (such as diabetes) or an abnormal urinary system
* recently having had a medical instrument inserted into the urethra
* sexual contact
A urinary tract infection in a man or child may be the sign of an abnormal urinary tract. For this reason, when men or children are found to have a urinary tract infection, they may be referred to a urologist (a specialist in diseases of the urinary system and the male reproductive system) for additional tests and x-rays.

Will you Need Further Tests After the Infection is Gone?

Once your infection has cleared, your doctor may recommend that you have additional tests. The tests are performed to assure that there are no abnormalities in the urinary tract that might result in kidney damage from urinary tract infections. Certain types of patients are most likely to need the tests. These types include:

* young children
* men
* people who have urinary tract infections that are frequent or that won't go away with treatment
* people who have had fever with the infection
* people who have had blood in the urine

What Else may Feel Like a Urinary Tract Infection?

The symptoms of a urinary tract infection may resemble those of other urinary tract diseases. If no infection can be found or the infection won't go away, your doctor may refer you to a urologist to find out why. Other problems that the urologist may look for are described below:

* Urethritis may be either an inflammation or an infection of the urethra. When infection is present in the urethra, the condition often is due to bacteria passed by sexual contact.
* Interstitial cystitis is a bladder irritation found mainly in adult women; its cause is not known.
* Urinary stones sometimes develop in the bladder, irritating it and causing symptoms similar to those of a urinary tract infection. On occasion, the stones have bacteria inside that trigger hard-to-cure infections.
* Bladder tumors (cancerous or noncancerous growths), when present, may irritate the bladder. The symptoms often include a frequent need to urinate and possibly blood in the urine.
* Prostatitis is an inflammation or infection of the male gland, the prostate, which surrounds the urethra just below the bladder. In adult males, prostate disorders may cause symptoms that resemble those of urinary tract infections.

Do Urinary Tract Infections have Long-Term Effects?

Urinary tract infections in most adults can be successfully treated without causing long-term problems.
Young children have the greatest risk for kidney damage from urinary tract infections. Such damage may lead to poor kidney function, high blood pressure, and other problems. For this reason, it is importantthat children with urinary tract infections receive prompt treatment and careful checkups.
Pregnant women with a history of repeated urinary tract infections should have their urine tested often. Urinary tract infections during pregnancy can cause serious kidney infections in the mother and possible risks for the baby.

What Steps can you Take to Help Prevent these Infections?

The following are steps you can take to reduce your risk of getting a urinary tract infection:

* Don't postpone--urinate when you feel the urge.
* Don't rush--take your time when you urinate to empty your bladder completely.
* Respond to your body's signals of thirst by drinking enough water or other liquids every day.
* Urinate after having sex. (Of course, using condoms during intercourse--practicing safe sex--is wise for many reasons.)

Women

* After urination, wipe with tissue from front to back, never back to front.
* When urinating, sit on the toilet with your legs spread several inches so the flow of urine is not obstructed.
* Drink eight glasses or more of fluids every day.
* Consult your doctor at the first sign of a problem. Urinary tract infections are very common, and they are easiest to treat if caught before they become severe or spread beyond the bladder.

Symptoms



The symptoms of BPH usually involve problems with emptying the bladder or storing urine in the bladder. However, the severity of the symptoms can vary widely, from mild and barely noticeable to serious and disruptive. Interestingly, the size of the prostate enlargement is often not related to the intensity of the symptoms; slight enlargements may produce serious symptoms, or significant enlargements may result in few symptoms.

Common BPH symptoms include:

  • Pushing or straining to begin urination
  • A weak urinary stream
  • Dribbling after urination
  • A frequent need to urinate, sometimes every 2 hours or less
  • A recurrent, sudden, or uncontrollable urge to urinate
  • Feeling the bladder has not completely emptied after urination
  • Pain during urination
  • Waking at night to urinate

In extreme cases, a man may be completely unable to urinate. In such situations, emergency medical attention is required.

An enlarged prostate does not directly affect sexual function. However, many men experience sexual dysfunction and BPH symptoms at the same time. This is due to aging and the common medical conditions older men often encounter, including vascular disease and diabetes. Since all these conditions take place with aging, sexual dysfunction tends to be more pronounced in men with BPH.

While the symptoms above may indicate an enlarged prostate, sometimes they point to a different problem. For instance, they may be caused by a urinary tract infection involving the bladder, ureters, or the kidney; a chronic infection of the prostate; or a medication.

To assess BPH symptoms, the American Urological Association (AUA) has created a list of questions called a Symptom Score Index. It can help you evaluate your symptoms—from mild to severe—and, later, help you measure the success of your treatment.

The Diagnosis




When your symptoms suggest BPH, your doctor may send you to a urologist. To confirm an enlarged prostate, your urologist will begin with a physical examination, study your medical history, and evaluate your symptoms. Then, a series of tests will be performed. These tests may vary from patient to patient, but can include the following:

  • Tests often performed:
  • Digital rectal exam (DRE)—checks the size and firmness of the prostate. The size of the prostate does not always determine the severity of the symptoms; a man with a small amount of prostate enlargement may have more severe symptoms than a man with a more significant enlargement.
  • Urinalysis and urine culture—check for a urinary tract infection that might be the cause of the symptoms.
  • Prostate-specific antigen (PSA) test—a blood test that helps check for prostate cancer, which can cause symptoms similar to those of an enlarged prostate.

Other tests that may be performed:



Post-void residual urine test (PVR)—measures the amount of urine left in the bladder after urination.
Pressure flow study—measures pressure in the bladder during urination.
Cystometrogram—measures bladder pressure and the storage capacity of your bladder.
Uroflowmetry test—measures how fast the urine flows out of the bladder.

Laser Prostatectomy (HOLEP)




 About the Surgery

Laser prostatectomy is an alternative to Transurethral Resection of the Prostate, TURP. It is used to treat patients with urinary symptoms due to benign prostate enlargement (Benign Prostatic Hypertrophy, BPH). Instead of using electrical energy, it uses a high-energy laser to remove the core of the prostate from inside the gland to create an open channel, whilst avoiding the muscles and nerves that are important to maintain urinary continence and erectile function. The types of laser surgery include:

• Holmium laser enucleation of the prostate (HoLEP). In general this technique can be used for large prostates. It provides results similar to TURP, but with less chance of bleeding and a shorter recovery time. Therefore, it works best for patients with bleeding problems or multiple other health conditions.

 Aim of Surgery

Relief of urinary symptoms – stronger flow, less frequent toilet visits day and night, less urgency to urinate.

 How Long is Surgery

90 min

 Anaesthetic

General Anaesthetic is the preferred method for this procedure.
(You are put to sleep for the whole operation and will feel no pain or discomfort during the procedure)
OR
Spinal anaesthesia – injection into the back (numb below waist)

 Incision/Cut

>No skin incisions – the entire operation is performed through the opening of the penis

 Description of Surgery

An instrument called a resectoscope is inserted through the opening of your penis. It has a telescope and an electrical cutting loop at the end which enables the surgeon to view and remove the part of the prostate that is causing the blockage. The loop “cores” out the inside of the prostate one piece at a time to create an open channel. Irrigating fluid flows through the resectoscope continuously, removing tissue debris from the bladder. A urinary catheter (a narrow tube that is passed through the opening of the penis into the bladder) is inserted at the end of surgery

 Complications of Surgery

“Dry ejaculation” (Retrograde ejaculation) – semen passes backwards into the bladder during ejaculation instead of passing down the urethra

Excessive bleeding - may occur up to 6 weeks after surgery (even after your urine is normal in colour)

Not able to pass urine – due to clots, swelling of bladder or bladder weakness requiring reinsertion of the urinary catheter for up to 2 weeks.

Loss of bladder control (Incontinence) – usually improves in a few weeks but may be permanent (very rare)

Erection problems 3-10%

Infection 5%

Scarring of the bladder neck causing narrowing (stricture)

Injury to rectum (very rare)

TURP syndrome – excessive absorption of irrigating fluid (less common compared to conventional TURP surgery)

 Duration of Hospital Stay

1-2 days (usually shorter stay compared to TURP surgery)

 MONTH BEFORE

Contact your urologist if you have been admitted to hospital for a medical problem in the last 4-6 weeks of surgery (eg heart attack, stroke, pneumonia)

 WEEK BEFORE

Most patients need to STOP taking their blood thinning medications 7-10 days before surgery. If you have not received clear instructions on what to do and are still taking the medication, contact your surgeon or local doctor immediately.

 DAY BEFORE

If you do not have diabetics OR are a diabetic on diet control only:
Fast from MIDNIGHT (no food or drinks) before if surgery is due in early morning (0800 hours). Do not take your diabetes tablet medication

If you have diabetes and are on insulin:
Because you are fasting, most patients take only half their usual insulin dose in the morning when it is due. Have a sweet drink or snack if you develop symptoms of low sugar (hypoglycaemia).

 THINGS TO PACK

Bring firm, supportive fitting underwear, such as jocks to wear after surgery for comfort and to decrease the risk of swelling

ALL relevant tests – ultrasound scans, x-rays, blood and urine tests.

ALL current medication

When Your Kidneys Fail




Healthy kidneys clean your blood by removing excess fluid, minerals, and wastes. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, harmful wastes build up in your body, your blood pressure may rise, and your body may retain excess fluid and not make enough red blood cells. When this happens, you need treatment to replace the work of your failed kidneys.



How Transplantation Works



Kidney transplantation is a procedure that places a healthy kidney from another person into your body. This one new kidney takes over the work of your two failed kidneys.

A surgeon places the new kidney inside your lower abdomen and connects the artery and vein of the new kidney to your artery and vein. Your blood flows through the new kidney, which makes urine, just like your own kidneys did when they were healthy. Unless they are causing infection or high blood pressure, your own kidneys are left in place.



The Transplant Process




Your Doctor’s Recommendation

The transplantation process begins when you learn that your kidneys are failing and you must start to consider your treatment options. Whether transplantation is to be among your options will depend on your specific situation. Transplantation isn’t for everyone. Your doctor may tell you that you have a condition that would make transplantation dangerous or unlikely to succeed.

Medical Evaluation at a Transplant Center

If your doctor sees transplantation as an option, the next step is a thorough medical evaluation at a transplant hospital. The pretransplant evaluation may require several visits over the course of several weeks or even months. You’ll need to have blood drawn and x rays taken. You’ll be tested for blood type and other matching factors that determine whether your body will accept an available kidney.

The medical team will want to see whether you’re healthy enough for surgery. Cancer, a serious infection, or significant cardiovascular disease would make transplantation unlikely to succeed. In addition, the medical team will want to make sure that you can understand and follow the schedule for taking medicines.

If a family member or friend wants to donate a kidney, he or she will need to be evaluated for general health and to see whether the kidney is a good match.

Placement on the Waiting List

If the medical evaluation shows that you’re a good candidate for a transplant but you don’t have a family member or friend who can donate a kidney, you’ll be put on the transplant program’s waiting list to receive a kidney from a deceased donor—someone who has just died.

Every person waiting for a deceased donor organ is registered with the Organ Procurement and Transplantation Network (OPTN), which maintains a centralized computer network linking all regional organ gathering organizations (known as organ procurement organizations, or OPOs) and transplant centers. The United Network for Organ Sharing (UNOS), a private nonprofit organization, administers OPTN under a contract with the Federal Government.

UNOS rules allow patients to register with multiple transplant centers. Each transplant center will probably require a separate medical evaluation, even if a patient is already registered at another center.

Observers of OPTN operations have raised the concern that people in certain regions of the country have to wait longer than others because allocation policies for some organs give preference to patients within the donor’s region. Kidneys, however, are assigned to the best match regardless of geographic region. The Federal Government continues to monitor policies and regulations to ensure that every person waiting for an organ has a fair chance. The key to making waiting times shorter is to increase the number of donated organs.

Waiting Period

How long you’ll have to wait depends on many things but is primarily determined by the degree of matching between you and the donor. Some people wait several years for a good match, while others get matched within a few months.

While you’re on the waiting list, notify the transplant center of changes in your health. Also, let the transplant center know if you move or change telephone numbers. The center will need to find you immediately when a kidney becomes available.

OPOs are responsible for identifying potential organs for transplant and coordinating with the national network. The 69 regional OPOs are all UNOS members. When a deceased donor kidney becomes available, the OPO notifies UNOS, and a computer-generated list of suitable recipients is created. Suitability is initially based on two factors:

  • Blood type. Your blood type (A, B, AB, or O) must be compatible with the donor’s blood type.

  • HLA factors. HLA stands for human leukocyte antigen, a genetic marker located on the surface of your white blood cells. You inherit a set of three antigens from your mother and three from your father. A higher number of matching antigens increases the chance that your kidney will last for a long time.

If you’re selected on the basis of the first two factors, a third is evaluated:

  • Antibodies. Your immune system may produce antibodies that act specifically against something in the donor’s tissues. To see whether this is the case, a small sample of your blood will be mixed with a small sample of the donor’s blood in a tube. If no reaction occurs, you should be able to accept the kidney. Your transplant team might use the term negative cross-match to describe this lack of reaction.

Transplant Operation

If you have a living donor, you’ll schedule the operation in advance. You and your donor will be operated on at the same time, usually in side-by-side rooms. One team of surgeons will perform the nephrectomy—that is, the removal of the kidney from the donor—while another prepares the recipient for placement of the donated kidney.

If you’re on a waiting list for a deceased donor kidney, you must be ready to hurry to the hospital as soon as a kidney becomes available. Once there, you’ll give a blood sample for the antibody cross-match test. If you have a negative cross-match, it means that your antibodies don’t react and the transplantation can proceed.

You’ll be given a general anesthetic to make you sleep during the operation, which usually takes 3 or 4 hours. The surgeon will make a small cut in your lower abdomen. The artery and vein from the new kidney will be attached to your artery and vein. The ureter from the new kidney will be connected to your bladder.

Often, the new kidney will start making urine as soon as your blood starts flowing through it, but sometimes a few weeks pass before it starts working.

Recovery From Surgery

As after any major surgery, you’ll probably feel sore and groggy when you wake up. However, many transplant recipients report feeling much better immediately after surgery. Even if you wake up feeling great, you’ll need to stay in the hospital for about a week to recover from surgery, and longer if you have any complications.



Posttransplant Care



Your body’s immune system is designed to keep you healthy by sensing “foreign invaders,” such as bacteria, and rejecting them. But your immune system will also sense that your new kidney is foreign. To keep your body from rejecting it, you’ll have to take drugs that turn off, or suppress, your immune response. You may have to take two or more of these immunosuppressant medicines, as well as medications to treat other health problems. Your health care team will help you learn what each pill is for and when to take it. Be sure that you understand the instructions for taking your medicines before you leave the hospital.

If you’ve been on hemodialysis, you’ll find that your posttransplant diet is much less restrictive. You can drink more fluids and eat many of the fruits and vegetables you were previously told to avoid. You may even need to gain a little weight, but be careful not to gain weight too quickly and avoid salty foods that can lead to high blood pressure