Tests and Treatments
On this page we list a number of tests and treatments which GPs may find useful as summary explanations when talking to patients.
Bladder neck incision
Problems with urinary flow are most often due to an enlarged prostate gland. In some cases however the problem may be due to the opening of the bladder or bladder neck. When this happens symptoms can be very similar to an enlarged prostate with poor urinary flow, incomplete bladder emptying and needing to urinate frequently. The operation to correct this is a cut or incision in the bladder neck to widen it. The approach to this and procedure are very similar to a transurethral resection of the prostate (TURP) though it takes a shorter time to perform.
Botulinum toxin into the bladder
For patients who have an overactive bladder with symptoms of going to pass water frequently, urgently or leaking urine before getting to the toilet in time, one option for treatment is injection into the bladder lining with botulinum toxin (often referred to as botox). This is performed using a flexible cystoscope whilst you are awake or with a rigid telescope whilst you are asleep. Sometimes, this treatment works too well and you may need to have a catheter placed to drain the bladder on a temporary basis or you may need to be taught to empty the bladder yourself on an intermittent basis. The effect of botulinum toxin is typically temporary and requires repeated injections, on average every nine months.
Circumcision is an operation to remove the foreskin. This operation is most commonly performed in adults because the foreskin is too tight and causes difficulty during erection or in passing urine. In some cases the foreskin or frenulum (on the underside of the foreskin) tears during intercourse. Often the foreskin is affected by the development of scarring or a condition called balanitis xerotica obliterans (BXO) which makes the skin tight. The operation is performed as a day case and takes about 30 minutes to perform and involved removal of the redundant and scarred foreskin. The remaining skin is then sutured together using dissolvable stitches which will fall out on their own.
This procedure for bladder stones involves a cystoscopy under a general anaesthetic to gain entry into the bladder. The bladder stone is then crushed with a special instrument or broken up with a laser. After the fragments are washed out, you may have a catheter placed overnight.
A cystoscopy is a telescopic examination of the urethra (waterpipe) and bladder. It is done with an instrument called a cystoscope that is used as a telescope to look into the bladder. It can be done under local anaesthetic using a flexible fibreoptic cystoscope (the procedure is called a flexible cystoscopy) or under general anaesthesia (or a spinal anaesthetic) using a rigid (metal) cystoscope.
A flexible cystoscopy is done in the setting of a clinic or daycase unit but can also be done in an operating theatre on occasions. It is usually done on an outpatient or daycase basis.
Cystoscopy using a rigid cystoscope is done to allow the passage of instruments along the cystoscope, to be used to do things in the bladder, such as taking a tissue sample (biopsy).
Epididymal cyst excision
A cyst can form attached to the tubes that arise from the back of the testicle. This can cause discomfort. To correct this would require a general anaesthetic operation usually undertaken as a daycase procedure. A small cut is made in the scrotum and the cyst is excised. The skin of the scrotum is usually closed with stitches that absorb and do not require removal at a later date.
Extracoporeal Shockwave Lithotripsy (ESWL)
This treatment is used when we have found a stone in the kidney or the ureter. It works by breaking up the stone(s) into smaller fragments which are small enough to pass on their own. This is achieved by shockwaves which are applied externally to the body and are focused to hit the stone by using Xrays and/or ultrasound imaging. You may require more than one session of treatment. The procedure, which usually takes between 30 to 60 minutes, is performed whilst you are awake but pain killers will be given to make it more comfortable. You will be able to go home after the procedure.
Female urinary incontinence procedures
There are a number of procedures available to treat involuntary loss of urine in a woman that can occur during activity such as coughing, walking or with exercise. One option is to inject agents around the waterpipe (the urethra) using a cystoscope under a general anaesthetic. This treatment option often requires a repeat procedure some time later. The second option involves supporting the urethra in a hammock type fashion. The support maybe provided by tissue taken from your own body or by a synthetic material. This operation involves a small vaginal incision and placing a sling that lifts the urethra. The third option entails more major surgery and involves making an abdominal incision and lifting the vaginal tissues that lie around urethra in a supportive manner. This last option would require a much longer stay in hospital, up to 3-5 days.
The frenulum is a band of tissue found on the underside of the head of the penis. A frenuloplasty is most commonly performed in adults because this band is too tight and becomes uncomfortable and stretched during erection. In some cases the frenulum may tear during intercourse. Unlike a circumcision where the whole foreskin is tight and needs removal, in a frenuloplasty only the band is divided to lengthen it. The operation takes about 15 minutes to perform and is commonly done as a day case procedure.
Having a fluid collection around the testicle can be troublesome. To correct this would require usually a daycase general anaesthetic operation. A small cut is made in the scrotum and the lining around the testicle that collects the fluid is excised and sutured. The skin of the scrotum is usually closed with stitches that absorb and do not require removal at a later date.
Sometimes urine is diverted away from the bladder because the bladder is diseased, for example from cancer or interstitial cystitis. One option is to place the tubes that lead from the kidneys (the ureters) into a segment of bowel (that has been disconnected from the rest of the bowel). This bowel piece would then exit your skin as a stoma. The urine draining from this stoma would then be collected into a bag.
Insertion of a ureteric stent
A stent is a plastic hollow tube that sits in the ureter (the tube between the kidney and the bladder). It is usually placed using a cystoscope during a general anaesthetic. The stent also has coils on both ends to keep the stent in place in the bladder and the kidney. A ureteric stent is used to allow urine to drain freely from the kidney to the bladder during instances of obstruction (eg from a stone or narrowing) or after ureteric injury. Stents can cause side effects such as urinary symptoms (eg frequency, urgency), pain or blood in the urine; these symptoms resolve when the stent is removed (usually with a flexible cystoscope under a local anaesthetic).
A laser prostatectomy is an alternative way of performing a TURP. In most centres this is done using a Holmium laser. In this procedure a laser is used to remove prostate tissue rather than using an electric current. This technique is thought to result in less blood loss and a shorter period of needing to have a catheter in. Although it is a relatively new technique the results in terms of improving men’s symptoms appear to be similar to TURP. Two forms of laser surgery are possible. Holmium Laser Resection of the Prostate (HOLRP) is an operation whereby prostate tissue is removed piece by piece and Holmium Laser Enucleation of the Prostate (HOLEP) where the prostate is removed in 2-3 large segments.
Male urinary incontinence procedures
There are a number of procedures available to treat involuntary loss of urine in a man that can occur during activity such as coughing, walking or with exercise. One option is to inject agents around the waterpipe (the urethra) using a cystoscope under a general anaesthetic. This treatment option often requires a repeat procedure some time later. The second option involves pulling up the urethra in a hammock type fashion using a synthetic sling. The third option involves placement of an artificial closure device (sphincter) around the urethra which is operated by a pump that lies in the scrotum.
Meatal / urethral dilatation and meatoplasty
A tightening can occur at the end of the natural waterpipe (urethra). To overcome this, usually under a general anaesthetic, a series of enlarging metal tubes are inserted to gently dilate the end of the urethra. Sometimes the end of the urethra is cut and refashioned with sutures to open the lumen (meatoplasty).
If you have developed a tightening (a stricture) to the water pipe in your penis, you will have difficulty in passing urine. This procedure involves a cystoscopy under a general anaesthetic and cutting the stricture with a special instrument. A catheter would then be placed and removed over 1-5 days later.
An orchidectomy is an operation to remove a testicle. This is most often done in adults because of the suspicion of testicular cancer. In this operation a cut/incision is made just above the hip line on the affected side and the testicular cord and testis identified and removed. The operation takes about 45 minutes to perform and can be done as a day case. In some circumstance a testicle may have to be removed because it has been injured or has become severely infected. In this situation an orchidectomy is performed thought an incision in the scrotum. Following an orchidectomy an artificial or prosthetic testicle can be placed in the scrotum to restore a normal appearance. While this can be done at the same time as an orchidectomy, it is more often done at a second operation.
Some boys may be born with a testicle that has failed to descend normally into the scrotum. In many cases this corrects as the child gets older. When this does not happen, an operation to bring the testicles into the scrotum may be necessary. This is called an orchidopexy. In this procedure the testicle is identified and brought into scrotum and secured through the formation of a pouch of muscle.
The prostate specific antigen or PSA test is a test used for the detection of prostate cancer. This test is done by taking a blood sample and sending it to the laboratory. It is used commonly as one of the first tests in suspected prostate cancer together with a prostate examination. An elevated PSA does not necessarily imply a diagnosis of prostate cancer and can be raised for a number of reasons.
The PCA 3 test is a test done using urine samples taken after a urologist has done a massage of the prostate gland during a rectal examination. It is most often used where prostate cancer is suspected but a biopsy of the prostate shows no prostate cancer. The PCA 3 test has been suggested to be a better test than PSA, for the purpose of detecting prostate cancer . It is not however an alternative to getting a tissue sample of the prostate (link to prostate biopsy) which is currently the most reliable way to diagnose prostate cancer. The Cambridge Urology Clinic consultants believe that the PCA3 test has a specific role in helping diagnose prostate cancer in some men and we are happy to offer this test to patients. More importantly however, we offer full discussion about the benefits, limitations and use of this test.
Percutaneous nephrolithotomy (PCNL)
This treatment is used when we have found a stone in the kidney. It involves a general anaesthetic operation where a telescope is passed into your kidney through your side via a puncture through your skin. Through this telescope, the stone is fragmented and then removed. You will usually be left with a stent in the ureter and/or a tube exiting the kidney through your skin. These tubes are then removed during your inpatient stay or at a later date.
A prostate biopsy may be necessary if there is a suspicion of prostate cancer. In this procedure an ultrasound probe is passed into the rectum to visualise the prostate. Using local aesthesia 10-12 tissue biopsies are taken from the prostate using fine needles. These tissue biopsies are then sent to the laboratory to be checked. The procedure takes about 20 minutes. A common side effect is blood in the urine and rectum but this is short lived. There is also a small risk of infection and all men will be given antibiotics before and after the procedure.
This is an operation to remove the prostate in its entirety. It is primarily recommended for men with disease confined to the prostate. In this operation the prostate and seminal vesicles are removed and the bladder is joined to the urethra. The operation has a high success rate in curing prostate cancer if the disease is caught early enough. The operation involves an in hospital stay of about 3-4 days and a catheter is left in place for about 7-10 days afterwards. The main long term side effects of this operation are incontinence (whereby men may leak urine) and erectile dysfunction. In the UK this operation can be done by open surgery, laparoscopic surgery or robotic surgery. Consultants at The Cambridge Urology Clinic work in the department of urology in Addenbrookes hospital where the operation is done using the Da Vinci Robotic system.
Sacral nerve stimulation
For patients who have an overactive bladder with symptoms of going to pass water frequently, urgently or leaking urine before getting to the toilet in time, one option for treatment is to stimulate the nerves to the bladder that lie in the sacrum. If you were to have this treatment, you would have a temporary electrode placed in to the nerves that lie in the sacrum under a general anaesthetic and have these nerves stimulated. If the treatment was successful (by studying the improvement in your bladder symptoms) you would have a second procedure under a general anaesthetic to have a permanent electrode placed and a permanent stimulator inserted into the muscles that lie in the upper half of the buttock area. This stimulator contains a battery that lasts for five years and then requires replacement.
Suprapubic catheter (SPC) insertion
Some people are unable to pass water for a variety of reasons. A way of dealing with this is to have a urethral catheter inserted through the natural waterpipe (urethra). A longer term solution to this would be to have a catheter that is placed though your abdominal wall into the bladder. Placement of this catheter will require a general anesthetic operation. The advantage of this type of urine drainage is that the catheter is more easily replaced and can lead to less discomfort through the urethra.
Sometimes urine is diverted away from the bladder because the bladder is diseased, for example from cancer or interstitial cystitis. One option is make a new storage container from a long segment of bowel (that has been disconnected from the rest of the bowel) and reconfigured this bowel segment into a sphere shape. The tubes that lead from the kidneys (the ureters) would then enter this new sphere inside your abdomen and you would then empty it by placing a catheter inside intermittently.
Transurethral resection of bladder tumour (TURBT)
Bladder cancers that affect the lining of the bladder are removed by this technique. This would be done by a general or spinal anaesthetic operation where a telescope is passed through the natural waterpipe (urethra) and the lesion is cut away from the bladder lining. After the operation, a temporary urinary catheter will be left in place and you may have instillation of a chemotherapy drug (Mitomycin C), which may be used to reduce the chances of further trouble from the tumour.
Transurethral resection of the prostate (TURP)
Many men will experience problems with their urinary flow as they get older. In most cases this is due to a normal enlargement of the prostate or Benign Prostatic Hyperplasia (BPH). Symptoms can include a poor flow, a feeling that the bladder is never empty and a need to pass urine in the day and night more frequently. In severe cases a complete inability to pass urine or urinary retention may develop. The first treatment is usually medication designed to shrink or relax the prostate. For some men however this will not work and the next step is as an operation to re-bore the prostate. A TURP is performed through the natural urinary passage and uses an electric tool to core out the centre of the prostate and hence widen the channel for urine to flow. The procedure requires an inpatient stay of about 2 days and a catheter is placed temporarily and removed just before discharge.
Ureteroscopy – diagnostic
This procedure is usually performed to investigate causes of bleeding in the urine. It involves passing a fine telescope (which can flexible or rigid) through the waterpipe, into the bladder and then up the ureter (the pipe that leads from the kidney to the bladder) into the kidney. This is performed under a general anaesthetic; you will usually be able to go home after the procedure. A ureteric stent is sometimes left in place after the procedure.
Ureteroscopy and stone destruction
This procedure is performed to break up a stone in the ureter (the pipe that leads from the kidney to the bladder) or kidney. It involves passing a fine telescope (which can be flexible or rigid) through the waterpipe, into the bladder and then up to the ureter or kidney depending on where the stone is. The stone is then fragmented using a laser. Sometimes a retrieval device such as a small metal basket is used to remove the stone fragments. Sometimes, the stones are fragmented to such a small size that you will be expected to pass the tiny fragments in your urine at a later time. The procedure is performed under a general anaesthetic and usually requires a minimum of a one night stay in hospital. A ureteric stent is sometimes left in place after the procedure which will require later removal with a flexible cystoscope under a local anaesthetic.
This involves major surgery to repair or replace the ureter (the tube between the kidney and the bladder). There are a number of ways that this can be achieved – by cutting away the diseased area and rejoining the two ends of the ureter, by creating a tube from the bladder to act as a ureter, by swinging one ureter over to the other, or by replacing the ureter by creating a new tube made from bowel. A ureteric stent would also be placed.
If you have developed a tightening (a stricture) to the water pipe in your penis, you will have difficulty in passing urine. Rather than cutting the stricture, you may gain greater benefit from having the water pipe remade. This can either involve cutting away the diseased area and either rejoining the ends or creating a new tube, typically from tissue from the lining of your mouth. This may involve two operations. You would have a catheter placed to drain the bladder and would need to stay in hospital for up to five days.
This is an outpatient investigational procedure used to determine why you may have urinary symptoms. The test involves having a fine catheter placed into your bladder and another fine catheter placed into the rectum. Your bladder will be filled and you will be asked a series of questions on the sensations you experience as your bladder fills. You will then be asked to empty your bladder. Throughout the test, the pressure in your bladder will be monitored. The procedure will take one to two hours.
This sterilisation operation involves cutting the tube (the vas) that come from each testicle that carry the sperm. Usually by local anaesthetic, small incisions are made in the scrotum, the vasa are identified, divided and the ends tied. You will be asked to provide two semen samples usually around 4 months to check there is no further viable sperm. You will need to continue to use alternative forms of contraception until you receive notification that it is safe not to do so, sometimes this requires further semen samples after the initial two provided.
This operation is performed when a man has had a vasectomy and circumstances have changed such that a reversal procedure is requested. The success of the operation is largely dependent on the time interval since the initial vasectomy was performed. The operation involves a general anaesthetic, delivering the ends of the cut tube (the vas) that come from each testicle that carry the sperm and rejoining the ends. It may take up to a year for viable sperm to reappear. More information is available at www.reconnectvasectomyreversal.com.