Onabotulinum Type-A, A.K.A botox, is not only for turning back the hands of time and erasing those pesky fine lines…
Botox is a saving grace for people suffering from conditions such as chronic migraines, neck spasms, excessive sweating, lazy eye and certain conditions relating to incontinence.
The following urinary conditions can be treated with botox therapy:
This refers to the abnormal function of the lower urinary tract. This includes the bladder, bladder neck, and/or its sphincters.
The following article will focus on how botox therapy can help those suffering from an overactive bladder (OAB).
The cause of an overactive bladder is essentially a malfunction of the detrusor muscle found in the bladder wall. During urination, the pelvic, abdominal and bladder muscles contract. The detrusor muscle in the bladder wall contracts to help force urine from the bladder and into the urethra.
Below is a simple diagram of the bladder; the detrusor muscle is highlighted in blue.
Simple diagram of a bladder, highlighting the detrusor muscle in blue.
An overactive bladder is characterised by dysfunctional detrusor muscle activity. The detrusor muscle contacts when it is not supposed to; meaning that one will experience an overwhelming urgency to urinate when the bladder isn’t full.
A simple diagram to illustrate the difference between a normal functioning bladder and an overactive bladder.
Botox helps to regulate dysfunctional and inappropriate contractions of the detrusor muscle. Botox helps the muscles to relax and therefor alleviates sudden and sometimes uncontrollable urges to urinate.
How is the procedure performed?
Depending on which medical centre/clinic/hospital you attend, a botox installation can take place under local or general anaesthetic.
If done under local anaesthetic while the patient is awake, the bladder is numbed before the procedure and injections begin.
Once the patient is numbed/asleep, an instrument called a cystoscope is passed up into the bladder via the urethra. This is a thin flexible tube with a very small camera on the end that allows the doctor to visualise the inside of organs (such as the bladder in this case). A very fine needle and botox delivery system will be attached to the scope as well. With the help of the visual feedback from the cystoscope, the doctor is able to administer a series of botox injections to the bladder wall.
Simple illustration showing the inside of a bladder with a cystoscope
The actual injecting takes only a couple of minutes. The procedure is virtually painless; however patients that have had this procedure done under local anaesthetic describe the sensation as being similar to a period cramp.
Conservative Treatment Methods & Alternatives
Prior to resorting to operative measures, some doctors may feel that conservative avenues should be pursued first.
Conservative treatment methods are not permanent solutions to the problem of OAB. They would merely be a way to avoid having to undergo a medical procedure.
The following options may be suggested to you by your treating doctor:
Infographic showing a list of conservative treatments for OAB
Of all the urological cancers, primary urethral cancer (PUC) is one of the rarest occurring malignancies (cancers). PUC accounts for less than 1% of all cancers.
The urethra is the duct that connects the meatus (opening) of the penis/vagina to the bladder. It is the final “pipe” in our plumbing that drains urine from the bladder.
The male and female urethra differ in length. An average male urethra measures +/- 21cm in length and the average female urethra is +/- 4cm in length. The male urethra incorporates the prostate gland, situated just below the bladder. The mucosal membrane that lines the urethra is composed of transitional epithelium at the bladder and progressively changes along the urethra to squamous epithelium.
The image below depicts a diagram of both the male and female lower urinary tract, with the respective urethras highlighted in blue.
Male and female urethra highlighted in blue.
There are three main subtypes of PUC, which are; urothelial carcinoma (UC), squamous cell carcinoma (SCC) and lastly adenocarcinoma (AC). Men commonly develop UC, followed by SCC and AC; whereas, AC is the most common in women followed by SCC and UC.
Risk Factors
Risk factors for developing PUC are similar between males and females; however, females arguably have more factors placing them at risk than males do.
Females
History of bladder cancer
Chronic inflammation
Caruncles (Of the urethral opening)
Leukoplakia (Of the genitalia)
Urological trauma
Frequent urinary tract infections (UTI's)
Sexually transmitted diseases (STD's)
Human Papilloma Virus (HPV)
Sexual activity
Diverticula
Child birth
Being 60 years of age and older
Males
History of bladder cancer
Urethral stricture
Chronic inflammation
Sexually transmitted diseases (STD's)
Human Papilloma Virus (HPV)
Urological trauma
Sexual activity
Being 60 years of age and older
Symptoms
Certain symptoms of PUC will be shared by both men and women; however structural differences in genital anatomy mean that certain symptoms pertain only to men or women respectively.
Bleeding from the urethra
Blood in the urine
Frequent urination
Enlarged lymph nodes in groin
Weak and/or interrupted flow of urine
Frequent and/or urgent bowel movements
Discharge from the urethra (can be foul smelling or contain pus)
Urinary retention
Lump or thickness in the perineum or penis
Painful and/or uncomfortable intercourse
Priapism (persistent and painful erection)
Pain and/or swelling in the urethra, suprapubic region or the perineum)
Diagnosis
As is standard with all cancerous tumours, early detection provides patients with the best possibility of cure. PUC is notoriously difficult to diagnose which is why your doctor will perform multiple diagnostic tests if they suspect you have PUC. In order to accurately diagnose and stage PUC, doctors will use a combination of the following:
Physical examination – Early detection and evaluation normally occurs during a thorough physical examination. This should include the meticulous examination of the genitalia and rectum.The examination of male patients should include palpation of the entire urethra and perineum.
Care should be taken to palpate regional lymph nodes; enlarged lymph nodes may need to be surgically removed in the event of a cancer diagnosis. The discovery of the presence of fistula on the perineum may be indicative of advanced stage PUC.
Laboratory studies – Lab studies refer to blood, urine and other specimen testing. These studies are unable to provide doctors with a definitive answer and/or diagnosis for suspected PUC patients. However, results from blood and urine analysis can help doctors rule out symptom suggested issues such as urinary tract infection. Results from various blood tests such as liver function tests can be a good indicator as to whether or not there is metastasis.
Imaging studies – Magnetic Resonance Imaging (MRI) scans provide doctors with a comprehensive view of the human body that cannot be achieved by alternative imaging techniques. This wealth of visual data helps expedite the process of diagnosis, staging and treatment planning.
In addition to diagnostic capabilities, MRI scans afford doctors the ability to evaluate whether or not chemotherapeutic/radiation treatment is helping to shrink cancerous tumours.
Biopsy – The only way to definitively diagnose and stage PUC is through a transurethral (via the urethra) biopsy. In order to obtain a biopsy specimen, a small piece of tissue is removed from the suspected cancerous area. After the tissue sample is harvested, the specimen is sent for laboratory testing and examination. Lab technicians will examine the sample in order to establish the presence of malignant cells, the stage and type of cancer.
The rarity of this cancer and its ability to evade detection mean that PUC often goes undiagnosed until the disease has progressed into the advanced stages. In order to afford patients the best survival outcome and chance of cure, it is paramount that cancers like PUC are detected and diagnosed earlier rather than later.
Treatment
Unfortunately, the low frequency at which PUC occurs means that modern medicine has yet to definitively establish the gold standard in terms of an appropriate treatment regime to combat this particular cancer.
The stage and location of the tumour will determine the treatment approach taken by doctors.
Current approaches taken to treat PUC include; multimodal therapies, radical surgery and regional lymphadenectomy (removal of lymph nodes).
Radiation therapy – Radiotherapies for PUC would include external beam radiation (EBR) and/or brachytherapy. Radiation therapy has been used as the only treatment modality for advanced stages of PUC in the past; however, radiation therapy most commonly used in conjunction with chemotherapy and/or surgery, forming the multimodal approach.
Chemotherapy – In the majority of PUC cases, chemotherapy has played a role in the treatment plan. An exact combination of chemotherapeutic agents has yet to be established to best combat PUC; however, depending on the type of cancer (SCC, AC or UC) usually a combination of three of the following agents has shown promising results in previous PUC patients; cisplatin, gemcitabine, ifosfamide, 5-fluorouracil, methotrexate, vinblastine and doxorubicin.
Surgical treatment – Depending on the size, location and depth of the tumour, surgical approaches to treating PUC include the following: partial or total penectomy (surgical removal of the penis), transurethral resection or urethrectomy (surgical removal of the urethra).
For improved emotional and psychological outcomes in males, penile preservation is always of the utmost importance. However, in the case of metastatic or advanced PUC, survival often depends on the total removal of the penis.
Surgical approaches for women diagnosed with PUC often include partial or radical urethrectomy. When possible, partial urethrectomy is preferred in order to preserve urethral integrity.
In order to preserve penile function/length and urethral structure in both men and women; doctors must always consider and allow for reconstructive surgery when opting for radical surgical treatment.
In the event of regional lymph gland involvement, your doctor will most likely need to perform what is called lymphadenectomy. This entails the removal of lymph glands that have been invaded by cancer.
Multimodal therapy – Multimodal therapies form the standard treatment approach taken by doctors treating PUC. Doctors have found that a multimodal approach affords patients the best chance of long term survival without disease recurrence.
Multimodal therapies consist of a combination of the following, chemotherapy, radiation therapy and/or surgery.
Advanced stage PUC is commonly associated with metastasis (Tumour spread). The following sites are often the first to be invaded: prostate, bone and/or lymph nodes. In this event, the patient will require a multidisciplinary treatment approach. Depending on the site and extent of metastasis, this could include any of the following fields: radiologists, urologists, orthopaedics, gynaecologists, radiation oncologists and oncologists.
Prevention
There is no guaranteed way of ensuring that one does not develop cancer at some point in their life. However, there are measures one can take in order to reduce their over all risk of developing cancer. The following pertains particularly to PUC:
Reduce exposure to aromatic amines
Vaccinate yourself against HPV
Do not abuse pain killers
Regular self examination
Practice safe sex
Stop smoking
Definitions
Epithelium/Epithelial – This refers to the thin layer of tissue that makes up the lining/surface of an internal or external organ.
Transitional cell epithelium – These are the cells that make up the structures of the urinary system. These cells have the ability to change shape and stretch without breaking or sustaining damage.
Squamous cell epithelium – These are epithelial cells that get their name from their distinct flat and scale-like shape.
Radical surgery – The complete surgical removal of an organ or body part.
Transurethral – via the urethra.
Diverticula – Abnormal sac or pouch formation in a weak point in the wall of an alimentary tract.
Nowadays, the prevalence of kidney stones (also known as renal calculus/calculi) has risen, especially in modern society.
Doctors prefer for patients to pass small enough kidney stones themselves through the act of urination, however the human body often doesn’t take our preferences into consideration. Frequently, patients are unable to pass kidney stones due to the simple fact that they have grown too big. Without surgical intervention, patients will experience excruciating pain as well as possible life threatening complications in the inevitable event of a blockage.
It is extremely uncommon for a stone situated in the kidney to cause pain. This becomes an entirely different story when the stone – much like a ripe apple falling from a tree – detaches itself from the interior of the kidney and embarks on a journey to the bladder which is connected to the kidney via a small tube called the ureter. Unfortunately, if the stone is too large to pass it will most assuredly become lodged somewhere along the way, or become stuck on the wall of the ureter; which can have catastrophic and immediate painful ramifications. When the stone lodges in the ureter, the patient experiences colic, resulting in excruciating pain as well as possible medical complications.
Pain caused by kidney stones has been described as one of the worst pains a human can experience.
Possible outcomes of a renal blockage…
Kidney infection
Kidney damage
Kidney failure
Hydronephrosis – When the kidneys are unable to drain urine to the bladder – the urine accumulates in the kidneys. As a result the organ becomes engorged (swollen), which is excruciatingly painful and if left untreated will cause kidney failure and death. The kidney may rupture, relieving the pressure and preserving the organ. Otherwise the raised pressure will gradually destroy the kidney, usually within a couple of months.
The initial treatment is almost always analgesia with narcotic agents and anti-spasmodics, then a scan to assess the position and size of the stone. The urologist will make a decision at that point as to whether the stone will pass with or without surgical intervention.
Obviously, the best solution is when the patient can expel the stone(s) naturally, often with the assistance of medication for nausea and analgesics/muscle relaxants to ease the passage of the stone. Patients will be asked to void urine into a cup-like sieve to catch the stone. This allows the patient to see when the stone comes out and allows for the stone to be collected in order to be sent to a laboratory for analysis. Knowing the composition of the stone assists in preventing the growth of future stones.
If an operative solution is required, the technique used will depend on; stone position, size, hardness and the experience of the urologist.
Here are some root word definitions in order to facilitate the reader with understanding the various procedures.
Eg. Nephro–litho–tomy = Kidney stone removal
“Nephro-“ = Kidney
“-Litho” = Stone
“-Tomy” = Removal
“-Tripsy” = Crushed
“Lapara-“ = Abdomen (Soft part of abdomen between the ribs and hips)
“-Scope” = To see
Extracorporeal = From outside the body
Ureteral Stents
In medicine, the word “stent” can be defined as a temporary splint that is placed within a blood vessel, duct or canal in order to facilitate healing and/or alleviate a blockage.
Simple enlarged rendering of a Double J stent
A ureteral stent is a thin, hollow, flexible tube that surgeons insert into the ureter in order to prevent any blockages forming between the kidney and the bladder. A stent is normally inserted after a kidney stone procedure, it helps maintain adequate drainage of fluid from the kidney to the bladder. The stent also ensures that any stones passing from the kidney to the bladder, don’t become lodged in the ureter. The ureteral stents are commonly called, “double J stents” as each end of the stent is curled in order to ensure they remain in place.
There are various types of stents, all serve the same purpose but what sets them apart is the length of time they can be used for. Double J stents are intended for short term use – ideally a few weeks. Whereas, “indwelling” stents such as, Allium stents; can be left in for up to three years.
Risks associated with ureteral stents
Increased risk of ureteral infection
Ureteroscopy
A minimally invasive method of removing stones from a patient’s ureter, especially ones lodged close to the bladder. Commonly performed in the event that ESWL fails. A ureteroscopy is commonly performed under general anaesthesia.
A long, thin, flexible tube known as an ureteroscope (essentially the same as an endoscope) is passed through the urethra and bladder in order to access the ureter(s). A ureteroscope has a light and camera on one end so surgeons are able to visualise the inside of the patient without making a single incision.
There are two types of ureteroscope; semi-rigid and flexible. Semi-rigid scopes are often used for removing stones in the lower ureter, but can be used in the upper ureter if it is dilated enough to allow safe passage of the semi-rigid scope. A flexible scope is safer and less likely to cause trauma above the pelvic brim.
A flexible ureteroscope is used to remove stones in the kidney too small to address with ESWL.
Once the stone has been located, the urologist will discern whether or not the stone is small enough to be removed whole; or if it needs to be fragmented using a laser.
(In order from left to right) The visualisation and laser fragmentation of a kidney stone.
An instrument called a “basket” can be introduced along side the ureteroscope in order to grab and remove any stones or debris from the kidney, ureter, bladder or urethra. The basket resembles the wire end of a whisk, which can be extended and retracted inside the patient safely and with ease. Some patients may also require the insertion of a stent after the procedure; at the discretion of the urologist.
Examples of fully extended baskets
Patients can expect to be discharged on the same day as the procedure, provided there were no complications or unforeseen findings. Typically, regular daily activities can be resumed 2-3 days after the procedure.
Risks associated with ureteroscopy
Ureteral stent discomfort
Ureteral wall injury
Stone migration
Infection
Bleeding
Extracorporeal Shock Wave Lithotripsy (ESWL)
Extracorporeal shock wave lithotripsy, or ESWL is the least invasive form of kidney/ureteral stone removal; performed under general anaesthesia.
This treatment modality relies on a machine called a lithotripter to generate high-energy shockwaves that are directed at the kidney/ureteral stone. As a result, the shockwaves reduce the stone(s) to smaller fragments; the goal is to reduce stones to small enough sizes in order for the patient to safely expel them through urination.
For this nonsurgical treatment, the shockwaves are administered to the body via a soft water filled casing. The patient is positioned with the area intended for treatment placed against the casing which pulsates with each shockwave.
Simple diagram of lithotripter
If the surgeon feels that the stone fragments are still too large to safely and comfortably pass, a uretroscopy can easily be performed to remove the fragmented stone. Doctors prefer ESWL as it eliminates the need to make any incisions in the patient.
Patients can expect to be discharged on the same day as the procedure, provided there were no complications or unforeseen findings. Typically, regular daily activities can be resumed 2-3 days after the procedure
What makes a patient unsuitable for ESWL
Being the least invasive treatment modality for kidney stone removal, doctors would ideally rely on ESWL the most. However, there are certain factors that can make a patient an unsuitable candidate for ESWL.
Obesity
Pregnancy
Bleeding disorders
Severe skeletal abnormalities
Kidney cancer
Practitioners may be hesitant to suggest ESWL if…
Some factors may not exclude patients as candidates entirely, however practitioners may be cautious when considering ESWL as a treatment option. These factors include…
Chronic kidney infection
Scar tissue in the ureter
Stones consisting of cystine or calcium
Stones that need to be removed immediately
Having a cardiac pacemaker
Risks associated with ESWL
Bleeding around the kidney
Urinary tract infection
Blockage of urinary tract from stone fragments
Percutaneous Nephrolithotomy (PCNL)
A percutaneous nephrolithotomy (PCNL/PNL) is a form of treatment generally reserved for the larger kidney stones (20mm and bigger) or “staghorn” stones. Practitioners will also opt for this surgery in the event of ESWL/ureteroscopy failing or proving to not be viable. PCNL is performed with the patient under general anaesthesia.
In order to perform a PCNL, an incision is made in the patients flank over the kidney. A guide wire is inserted into the kidney under x-ray guidance through the incision. Graduated sheaths are placed over the guide wire to incrementally enlarge a tract directly to the kidney from the skin. A nephroscope is introduced into the kidney along the tract and the stone can the be visualised.
If the stones happen to be too large to remove whole, a laser can be used to reduce the stone to smaller fragments.
Patients can anticipate a 2-3 day long hospital stay after the procedure. Patient’s may require 1-2 weeks to recover in totality from the procedure.
Risks associated with PCNL
Bleeding
Renal pelvis perforation (Formation of a hole in the kidney)
Hydrothorax (Accumulation of fluid around the lungs)
Infection
Laparoscopic Ureterolithotomy
The main purpose of this procedure is to remove larger stones lodged in the ureter. In most cases, this procedure is only performed when less invasive methods fail. Laparoscopic procedures are performed under general anaesthesia.
Small incisions (generally 0.5-1.5cm long) are made in the patient’s abdomen, into which a laparoscope and carbon dioxide gas supplying tube is inserted. The laparoscope is similar to that of a endoscope, however they differ in that the optic tube is not flexible. The reason for filling the abdomen with gas, is to create more space which makes it easier for the surgeon to access and visualise the patient’s internal organs.
Additional small incisions will be made in order to insert the operative instruments. The surgeon will use a cutting and a grasping tool. Using the optic scope, the surgeon locates the affected kidney and ureter; a small incision is made in the ureter in order to remove the ureteral stones. Once all stones have been removed, the ureter is then stented and sutured closed.
Once the operation is completed the gas is released from the abdomen of the patient and all small incisions in the abdomen are sutured closed.
Patients can expect a hospital stay of 2-3 days granted no complications arose, and regular daily activities can be resumed within 2-3 weeks.
Open Surgery
Open surgery for kidney stones is the most invasive form of treatment and is considered to be the last resort if all other options fail. Open surgery is performed under general anaesthesia
Open surgery is only performed when alternative stone removal methods fail or prove to be insufficient. Surgeons may also have to resort to open surgery if the stones are abnormally large, especially in the case of “staghorn” stones. Patients born with a defect in their urinary system may require open surgery too.
To perform this surgery; once the patient is safely asleep, a large enough incision is made in the patient’s abdomen or side in order to expose the affected kidney and ureter. Wound retractors keep the surgical site open whilst the team operates. The surgeon will then make an incision in the organ, allowing access to the stones that need to be removed.
Once all stones have been removed, and any repair work is completed; the surgeon sutures the kidney closed and then does the same for the abdominal/flank incision.
Prior to closing, a catheter may need to be placed in the kidney. By doing so, urine can be drained from the kidney as the organ heals.
Patients can expect a hospital stay of 6-9 days and a recovery period of 4-6 weeks.
Risks associated with open surgery
Bleeding
Infection
Adverse reaction to anaesthesia
Increased chance of hernia developing at the incision sites
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