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Cloacal exstrophy

Cloacal exstrophy

Cloacal exstrophy

Cloacal exstrophy, also known as OEIS Syndrome, occurs when a portion of the large intestine lies outside of the body and on either side of it and connected to it are the two halves of the bladder. The intestine may be short and the anus may not open. The bony pelvis is also split open like a book. In males, the penis is usually flat and short, with the exposed inner surface of the urethra on top. The penis is sometimes split into a right and left half. In girls, the clitoris is split into a right half and left half and there may be one or two vaginal openings. Cloacal exstrophy (OEIS syndrome) is a very rare birth defect, affecting 1 in every 250,000 births. Although cloacal exstrophy is a serious condition and requires a series of operations, the long-term outcome is good for many children. Patients and families need to be counseled about the complexity of the anomaly, the need for multiple procedures, and long-term expectations for continence, sexual function, and fertility.

Cloacal exstrophy is known as OEIS Syndrome because of the four features that are typically found together 1:

  • Omphalocele: Some of the abdominal organs protrude through an opening in the abdominal muscles in the area of the umbilical cord. The omphalocele may be small, with only a portion of the intestine protruding outside the abdominal cavity, or large, with many of the abdominal organs (including intestine, liver and spleen) protruding outside the abdominal cavity.
  • Exstrophy of the bladder and rectum: The bladder is open and separated into two halves. The rectum and colon are similarly open and the segment of the rectum is placed between the bladder halves on the surface of the abdomen.
  • Imperforate anus: The anus has not been formed or perforated and the colon connects to the bladder.
  • Spinal defects: These defects may either be major or minor. Often children born with cloacal exstrophy are also born with some degree of spina bifida.

With cloacal exstrophy there are often other birth defects, like spina bifida. This occurs in up to 75 percent of cases. Kidney abnormalities and omphalocele are also common. An omphalocele is when an infant’s intestine or other abdominal organs are open to the outside the body. This is from a hole in the belly button (navel) area. The intestines are covered only by a thin layer of tissue and can be easily seen.

Cloacal exstrophy (OEIS Syndrome) is a complex anomaly that often requires several surgical procedures and requires lifelong medical follow-up care.

As soon as possible, surgical reconstruction is done. Surgery is major, and often done in parts. The schedule of surgery depends on the child’s condition and overall health. Surgery can return the bladder and bowel organs back into the body, to a healthy position. It can provide ways for bowel and urinary control, better kidney function, and improve the way the sex organs or genitals look.

Reconstruction surgery often starts within the first few days of life. It is sometimes delayed to allow the baby to grow and develop. Surgical repair is generally divided into steps and include:

  • Repair of spinal abnormalities, and if needed, the repair of a large omphalocele.
  • Once the child has recovered from spinal surgery, the gastrointestinal tract is treated. Many babies require a stoma because the colon is not normal, and the anus is not formed. The stoma will allow for waste to be released from the intestines to a pouch on the outside of the body.
  • Closure of the exposed bladder and bowel and reconstruction of the genitals are next. This may be done in steps if the pelvic bones are widely separated. For a successful closure, a pelvic osteotomy (cutting the bones to allow the pelvis to close more easily) is critical. In some cases, the abdominal wall, the bladder and genitals (genitourinary system) and the bowel may be repaired at the same time. Bladder reconstruction often includes the use of a catheter for some time.

Figure 1. Cloacal exstrophy

cloacal exstrophy

Cloacal exstrophy

[Source 2 ]

Figure 2. Cloacal exstrophy ultrasound

Cloacal exstrophy ultrasound

Footnote: Fetal ultrasound at 36 weeks’ gestation demonstrating bowel loops herniating between 2 bladder plates (“elephant trunk”).

[Source 3 ]

Figure 3. Cloacal bladder exstrophy female infant

cloacal bladder exstrophy female infant

Figure 4. Cloacal bladder exstrophy male infant

Cloacal bladder exstrophy male infant

Will my child be able to have children when they reach adulthood?

In many cases, the answer to this question is: yes. But almost always, assisted fertility is necessary for adults.

With regard to sexuality, males are generally potent, but some report inadequate phallus or residual curvature. Females report normal sexual function 4.

With respect to fertility and childbearing, retrograde ejaculation or iatrogenic obstruction of the ejaculatory ducts or vas deferens after surgical reconstruction may result in abnormal semen analysis. Antegrade ejaculation is preserved after single-stage repair, but abnormal semen parameters are common. However, fertilization, with viable pregnancy, has been achieved by male patients with cloacal exstrophy 5.

Females have had successful pregnancies 6. Cesarean delivery is recommended to avoid injury to continence mechanism. Postpartum uterine prolapse is common because of aggravation of preexisting abnormal pelvic support.

Cloacal exstrophy causes

The cause of cloacal exstrophy is currently unknown, so there is also no known way to prevent it. On the basis of the known embryologic principles of cloacal development, any inciting event would have to occur early in pregnancy.

There is a higher incidence of cloacal exstrophy in families in which one member is affected as compared with the general population. Offspring of patients with exstrophy-epispadias complex have a 1 in 70 risk (500 times that of the general population) of being affected. Nevertheless, familial occurrence is uncommon in large series 7. The heritability of cloacal exstrophy has not been established, because no offspring have been reported. Moreover, there’s no evidence to suggest that anything done by expectant parents leads to the condition.

At present, 22q11.2 duplication is the genetic variant most commonly associated with bladder exstrophy-epispadias complex 8.

Cloacal exstrophy has been reported in twins. Concordance rates show strong evidence of genetic effects 9, but less than 100% concordance among identical twins suggests some role for environmental effect on development of exstrophy-epispadias.

A higher incidence of bladder exstrophy is observed in infants of younger mothers and in those with relatively high parity.

Maternal tobacco exposure is associated with more severe defects (cloacal vs classic exstrophy).

Growing evidence suggests an increased incidence of cloacal exstrophy and bladder exstrophy-epispadias with in-vitro fertilization (IVF) pregnancies 10.

Cloacal exstrophy symptoms

In some cases, cloacal exstrophy is detected from a routine prenatal ultrasound. In other cases, it isn’t diagnosed until birth, when physicians can clearly see the exposed organs.

Antenatal ultrasound findings suggestive of exstrophy-epispadias complex include the following:

  • Repeated failure to visualize the bladder on ultrasound
  • Lower-abdominal-wall mass
  • Low-set umbilical cord
  • Abnormal genitalia
  • Increased pelvic diameter

Additional antenatal ultrasound findings suggestive of cloacal exstrophy include the following:

  • Omphalocele
  • Limb abnormalities
  • Myelomeningocele
  • Trunk sign from prolapsed intestine

Increased use of fetal magnetic resonance imaging (MRI) may further improve the accuracy of antenatal diagnosis, but this test is not necessary if suspicion is high on the basis of ultrasound findings.

Classic bladder exstrophy and cloacal exstrophy are obvious to all in the delivery room. Variants of the exstrophy-epispadias complex exist, including skin-covered bladder exstrophy, duplicate bladders, superior vesical fistula, and epispadias with major bladder prolapse 11. Most exstrophy variants and epispadias are also identifiable at birth. Unrecognized female epispadias may present as persistent childhood incontinence. Unrecognized split-symphysis variants of exstrophy may be identified in childhood only because of persistent incontinence or a waddling gait.

Physical examination

Patients with classic bladder exstrophy or epispadias typically appear as term infants. Patients with cloacal exstrophy, however, are often preterm. They may have respiratory embarrassment requiring mechanical ventilation.

Abdominal findings

In classic cloacal bladder exstrophy (see the images above), the bladder is open on the lower abdomen, with mucosa fully exposed through a triangular fascial defect. The abdominal wall appears long because of a low-set umbilicus on the upper edge of the bladder plate. The distance between the umbilicus and anus is foreshortened. The recti diverge distally, attaching to the widely separated pubic bones. Indirect inguinal hernias are frequent (>80% of males, >10% of females) because of wide inguinal rings and the lack of an oblique inguinal canal.

Nearly all patients with cloacal exstrophy have an associated omphalocele. The bladder is open and separated into two halves, flanking the exposed interior of the cecum. Openings to the remainder of the hindgut and to one or two appendices are evident within the cecal plate. Terminal ileum may prolapse as a “trunk” of bowel onto the cecal plate.

In cloacal exstrophy variants, the pubic symphysis is widely separated, and the recti diverge distally. The umbilicus is low or elongated. A small superior bladder opening or a patch of isolated bladder mucosa may be present. The intact bladder may be externally covered by only a thin membrane. Isolated ectopic bowel segments have been reported.

Genital findings

In describing the anatomy of the penis, the terms dorsal and ventral refer to a normal phallus in the erect state. The dorsal surface is in continuity with the abdominal wall, and the ventral surface is in continuity with the scrotum.

In cloacal exstrophy, the penis is generally quite small and bifid, with a hemiglans located just caudal to each hemibladder. Infrequently, the phallus may be intact in the midline. In females, the clitoris is bifid, and two vaginas are present. The anus is absent.

In exstrophy variants, the genitalia generally are intact (see the image below), though epispadias can occur.

In classic bladder exstrophy in males, the phallus is short and broad with upward curvature (dorsal chordee). The glans lies open and flat like a spade, and the dorsal component of the foreskin is absent. The urethral plate extends the length of the phallus without a roof. The bladder plate and urethral plate are in continuity, with the verumontanum and ejaculatory ducts visible within the prostatic urethral plate. The anus is anteriorly displaced with a normal sphincter mechanism.

In classic bladder exstrophy in females, the clitoris is uniformly bifid with divergent labia superiorly. The open urethral plate is in continuity with the bladder plate. The vagina is anteriorly displaced. The anus is anteriorly displaced with a normal sphincter mechanism.

In male epispadias, the phallus is short and broad with upward curvature (dorsal chordee). The glans lies open and flat like a spade, and the dorsal component of the foreskin is absent. The urethral meatus is located on the dorsal penile shaft, anywhere between the penopubic angle and the proximal margin of the glans.

In female epispadias, the clitoris is most often bifid with divergent labia superiorly. The dorsal aspect of the urethra is open distally. The urethra and bladder neck are patulous and may allow visualization of bladder. Bladder mucosa may prolapse through the bladder neck.

Musculoskeletal findings

In classic bladder exstrophy, the pubic symphysis is widely separated. Divergent rectus muscles remain attached to the pubis. External rotation of the innominate bones results in a waddling gait in ambulatory patients but does not appear to result in orthopedic problems later in life.

In cloacal exstrophy, the examination is the same as for bladder exstrophy. As many as 65% of patients have a clubfoot or major deformity of a lower extremity. As many as 80% of patients have vertebral anomalies.

In split-symphysis variants of exstrophy, the pubic symphysis is widely separated (see the image below), and the rectus muscles are divergent.

Neurologic findings

In cloacal exstrophy, as many as 95% of patients have myelodysplasia, which may include myelomeningocele, lipomeningocele, meningocele, or other forms of occult dysraphism. These patients are at risk for neurologic deterioration, and they should be observed closely. Early neurosurgical consultation is appropriate if a radiographic abnormality of the spinal cord or canal is observed.

Cloacal exstrophy diagnosis

Cloacal exstrophy can usually be diagnosed by fetal ultrasound before an infant is born. Upon birth, a physical exam will confirm the diagnosis.

Laboratory studies

Before complex reconstruction of the urinary tract, it is important to obtain information about the patient’s baseline renal function. In patients with cloacal exstrophy, losses from the terminal ileum short-gut physiology can result in significant electrolyte abnormalities.

Imaging studies

Baseline examination of the kidneys with ultrasonography is recommended for all patients with exstrophy because increased bladder pressure after bladder closure can lead to hydronephrosis and upper urinary tract deterioration. Congenital upper urinary tract anomalies are uncommon with classic exstrophy and epispadias but are present in approximately one third of patients with cloacal exstrophy (eg, ectopic pelvic kidney, renal agenesis, or hydronephrosis).

Spinal ultrasound or radiography may be helpful. Myelodysplasia should be excluded in newborns with cloacal exstrophy. This can be accomplished by means of ultrasound early in life. In cloacal exstrophy, magnetic resonance imaging (MRI) is recommended to help identify occult abnormalities that may predispose to symptomatic spinal cord tethering.

Bilateral vesicoureteral reflux (VUR) is present in nearly all patients with classic bladder exstrophy. Voiding cystourethrography (VCUG) is performed in early childhood to assess bladder capacity in preparation for reconstructive continence surgery. Evaluation of the bladder neck and proximal urethra is recommended in patients with epispadias in order to plan surgical management.

Managing pregnancy after a cloacal exstrophy diagnosis

Because cloacal exstrophy is a high-risk condition, you will need to be monitored throughout your pregnancy. In some cases, pregnancy may be complicated by polyhydramnios (excess amniotic fluid) during the third trimester, which may trigger preterm labor and delivery. Your delivery should also be planned at our state-of-the-art facility. This way, our delivery team can address any complications should they arise and the baby will have immediate access to treatment and the best surgical professionals.

Cloacal exstrophy treatment

Cloacal exstrophy is treated through surgical repair after birth, usually in stages to address each defect. This requires an in-depth treatment plan to be created for your child’s specific needs. The extent of cloacal exstrophy surgery required for your baby depends on the type and severity of his or her abnormalities.

Your child will undergo a series of surgeries over a number of years — referred to as staged reconstruction. The exact timing, nature and outcome of each cloacal exstrophy surgery will depend on your child’s particular situation. Your child’s surgeons will create a treatment plan based on the type and the extent of your child’s condition and discuss the plan with you. Usually surgery begins in the first days of life with the highest-priority procedure. Surgeons usually repair the bladder, create a colostomy (an opening in the colon with an attached “bag” that allows stool to pass) and repair the abdominal wall defect.

Babies with spinal defects usually have them repaired sometime in the first few days of life. Later surgeries include urinary and genital reconstruction, as well as an operation to create a rectum and close the colostomy opening. There are no fetal interventions (surgical procedures while inside the uterus) for cloacal exstrophy.

Treatment may include:

  • Abdominal repair: Typically, soon after your child is born, the surgeons will repair the omphalocele by closing the bladder and creating a colostomy so your child can eliminate stool. With a colostomy, the large intestine is separated from the bladder halves and reclosed. The two halves of the bladder are brought together and placed into the abdomen. The end of the large intestine is brought to the surface of the skin through an opening in the abdomen. A plastic bag, called a colostomy pouch, is placed over the opening to collect the stool.
  • Other surgery, such as surgery to repair the spine, may be planned around the initial stage of the abdominal repair.

After the initial surgery, your child will remain in the hospital where we will monitor the intestine as it begins to function. Our team will work with you and your family to ensure that the plan for your child is clear and that you have access to the supports you need.

  • Osteotomies: Once your child has healed from his first procedure and had some time to grow, we will schedule the second stage of the repair. This primarily involves working on the bladder. The orthopedic surgeon on our team will perform osteotomies to help ensure that your child’s pelvis can best support the bladder over time. During the osteotomy the hip bones are cut and adjusted. Your child will need to be in traction or in a spica cast for several weeks following this surgery.
  • Pull-through procedure: If your child was born with a significant amount of colon and is capable of forming solid stool, a surgical procedure, known as a “pull through” may eventually be performed. The purpose of this procedure is to connect the colon to the rectum.

Subsequent surgeries may also involve major urinary reconstructive surgery and further genital reconstruction. These issues will be discussed with you and your family as your child grows up.

Cloacal exstrophy repair

Reconstruction of exstrophy-epispadias complex remains one of the greatest challenges facing the pediatric urologist. Many modifications in surgical procedures have improved outcomes, but the optimal approach remains uncertain. Longitudinal prospective assessment of the two main current surgical approaches (staged procedure and total reconstruction) is critical for optimizing functional and cosmetic outcomes.

Complete primary reconstruction is now more than 20 years old; however, each approach is in a constant state of minor modification. Data on this approach continue to mature and are updated almost yearly 12. Analysis of each experience focuses on daytime continence with volitional voiding, need for further surgical procedures, and complication rates. In experienced hands, the safety and efficacy of the different approaches are comparable.

Goals of therapy include provision of urinary continence with preservation of renal function and reconstruction of functional and cosmetically acceptable genitalia. Creation of a neoumbilicus is also important to many of these patients.

Surgical techniques used in the treatment of exstrophy-epispadias complex include the following:

  • Staged functional closure for classic bladder exstrophy (ie, modern staged repair of exstrophy) 13
  • Complete primary repair for classic bladder exstrophy
  • Urinary diversion for classic bladder exstrophy
  • Closure for cloacal exstrophy
  • Gender reassignment

Staged functional closure for classic bladder exstrophy

Modern staged repair of exstrophy, which represents the traditional surgical approach, comprises a series of operations. Initial bladder closure is completed within 72 hours of birth. If this is delayed, pelvic osteotomies are required to facilitate successful closure of the abdominal wall and to allow the bladder to lie within a closed and supportive pelvic ring.

Epispadias repair with urethroplasty is performed at age 12-18 months. This allows enough increase in bladder outlet resistance to improve the bladder capacity.

Bladder neck reconstruction (typically a modified Young-Dees-Leadbetter repair) is performed at age 4 years. This allows continence and correction of vesicoureteral reflux (VUR). Multiple modifications have been proposed. The procedure is delayed until bladder capacity is adequate; better results are reported with a capacity greater than 85 mL.

Chua et al retrospectively studied a modification of staged exstrophy repair aimed at incorporating the advantages of complete primary repair for classic bladder exstrophy by avoiding concurrent epispadias repair and adding bilateral ureteral reimplantation and bladder neck tailoring (staged repair of bladder exstrophy with bilateral ureteral reimplantation) at the initial repair 14. They found staged repair of bladder exstrophy with bilateral ureteral reimplantation to be a safe alternative for exstrophy-epispadias repair, preventing penile tissue loss and yielding long-term outcomes comparable to those of complete primary repair for classic bladder exstrophy.

The radical soft-tissue mobilization (radical soft-tissue mobilization) procedure, also referred to as the Kelly repair, has been suggested as an alternative approach to staged reconstruction of bladder exstrophy 15. Radical soft-tissue mobilization has been performed not only as the second part of a two-step strategy (after bladder closure) but also as part of a combined procedure that includes delayed bladder closure and radical soft-tissue mobilization in a single stage without pelvic osteotomy 16.

Complete primary repair for classic bladder exstrophy

Compared with modern staged repair of exstrophy, complete primary repair for classic bladder exstrophy is a newer approach to exstrophy closure. Primary bladder closure, urethroplasty, and genital reconstruction are performed in a single stage in newborns. This procedure involves complete penile disassembly in males and mobilization of the urogenital complex in females. Hypospadias is a common outcome in males and requires subsequent reconstruction.

The goal is early bladder cycling. A subset of patients have achieved continence without bladder neck reconstruction.

In a study of 34 boys treated with a modified penile disassembly technique (15 with bladder exstrophy who underwent complete primary repair for classic bladder exstrophy, 11 with penopupic epispadias after previous closure of bladder exstrophy, and eight with isolated complete epispadias), Anwar et al found the modified technique to yield excellent cosmetic results 17. Preservation of the distal urethral plate along with both hemiglans avoided shortening and prevented occurrence of hypospadias.

Urinary diversion for classic bladder exstrophy

Urinary diversion was the original surgical treatment of choice. Diversion may be performed in a patient with an extremely small bladder plate not suitable for functional closure 18. In Europe, early diversion has been widely used, with success for most exstrophy patients.

Closure for cloacal exstrophy

Treatment of myelodysplasia and gastrointestinal anomalies has priority over management of urinary and genital anomalies.

Closure can be either staged or performed in a single stage, depending on the overall condition of the child and the severity of the abdominal wall defect. If a large omphalocele is present, successful closure of the abdomen and the bladder in one stage may be difficult to accomplish.

The first stage involves separation of the gastrointestinal and genitourinary (genitourinary) tracts, closure of the colon, creation of a colostomy, and closure of the omphalocele. The bladder plates are brought together in the midline.

Because virtually all of these patients have some element of short-gut syndrome, the hindgut should be incorporated into the gastrointestinal tract to maximize absorptive surface area. Ileostomy should be avoided because of the high incidence of recurrent hospitalizations for dehydration and severe electrolyte abnormalities. The decision between rectal pull-through and permanent colostomy is based on the surgeon’s preference and the projected potential for social fecal continence 19.

Subsequent bladder closure is carried out as in surgical management of classic bladder exstrophy. The principles of complete primary repair have been applied at this point as well. Consideration may be given to continent diversion as the second stage, on the basis of poor potential for volitional voiding and continence.

Because of more severe pubic diastasis, pelvic osteotomies are required. Staged pelvic osteotomy (staged pelvic osteotomy) with gradual closure of the pelvis may be needed in severe cases 20. In a study comparing staged pelvic osteotomy before bladder closure with combined pelvic osteotomy (combined pelvic osteotomy) at the time of closure in cloacal exstrophy patients, Inouye et al found that staged pelvic osteotomy reduced preoperative diastasis more than combined pelvic osteotomy did, without appearing to incur increased rates of complication, closure failure, or incontinence 21.

Gender reassignment

Historically, all males with cloacal exstrophy underwent early gender conversion because of inadequate male genitalia. Testicular histology is normal despite frequent cryptorchidism.

Evidence suggesting that testosterone in utero has a significant impact on the developing brain has led to a change in surgical philosophy, as has anecdotal evidence suggesting that raising a 46,XY cloacal exstrophy patient as female can result in significant gender dysphoria. Cloacal exstrophy is now included as a subset of disorders of sex development 22. Multidisciplinary evaluation and both early and long-term counseling should be offered.

Intraoperative concerns

Multiple or lengthy surgical procedures with exposure to latex antigens increase the risk of latex sensitization or allergy 23. Approximately 30% of patients with bladder exstrophy have demonstrated symptoms of latex allergy, and 70% reveal sensitization (elevation of specific immunoglobulin E [IgE] antibody) to latex antigens. For practical purposes, all patients with exstrophy-epispadias complex should be considered to be latex-sensitive.

Full latex precautions are recommended in the operating room, beginning with preparation for the first operative procedure. Potential latex-containing materials in the operating room include gloves, catheters, drains, masks, anesthesia materials, bandages, and thromboembolic stockings. Polyvinyl chloride and silicone are acceptable alternatives. Latex allergy should be considered seriously in the event of intraoperative anaphylaxis. The offending agent should be removed and the surgical procedure aborted if necessary.

Treatment includes cardiopulmonary resuscitation with fluids, epinephrine, steroids, and histamine blockade. In those with a known latex allergy, premedication with steroids and histamine H1 and H2 blockers should be considered.

After cloacal exstrophy repair

The goal of surgeons and doctors is to help improve the child’s quality of life. Better tools for anesthesia and infant nutrition have helped to increase the survival rate for newborns with this condition.

Postoperatively, patients with exstrophy remain in the hospital in modified Bryant traction (legs adducted and pelvis slightly elevated) for 3 weeks after bladder closure. Alternative techniques of immobilization may be used, based on osteotomies or institutional protocol.

Bladder and kidneys are drained fully with multiple catheters during the first few weeks after closure.

Nutritional support is mandatory for patients with cloacal exstrophy. Patients with classic bladder exstrophy may also have early difficulties feeding because of the body position in traction.

It’s important to work closely with your health care team to prevent infection after surgery, and learn about long-term care. After surgery, a child born with cloacal exstrophy can usually grow to manage urine and stool in a socially acceptable way. Further operations may be needed over time to improve the child’s ability to control their bladder and bowel function. More surgery may also be needed to rebuild and/or make better the outer sex organs.

Time and patience will be important for the parents and child. Neurologic issues from spina bifida, if present, can be managed, but requires ongoing medical care.

Complications

In the treatment of complex congenital anomalies, the distinction between technical complications and problems inherent to the anomaly is not always obvious.

Failure of closure may occur. If the bladder plate is adequate, reclosure with pelvic osteotomies is recommended. In this instance, bladder closure and epispadias repair are performed in one stage. Urinary diversion is the alternative therapy.

A vesicocutaneous fistula or urethrocutaneous fistula may form after primary closure or urethral reconstruction. If spontaneous closure does not occur, surgical repair is required.

Loss of the hemiglans or corporal body has been reported as a result of complete primary repair 24.

Minor orthopedic complications may occur after osteotomy or immobilization.

Upper urinary tract deterioration is a potential complication. Causes include excessive outlet resistance and high pressure in a small-capacity reservoir and persistent VUR.

Abnormal bladder function may result in poor emptying. Clinical problems related to poor emptying include recurrent febrile infections, epididymitis, bladder stones, acute urinary retention, and rupture of the native bladder.

Bladder prolapse is a potential complication. Posterior bladder wall may prolapse through the patulous bladder neck after primary closure (see the image below). Recurrent prolapse, congestion, ischemia of bladder mucosa, or failure of ureteral drainage warrants early surgical correction.

Malignancy is a rare late complication of bladder exstrophy and is more common in untreated patients whose bladders are left exstrophic for many years. Adenocarcinoma is the most common of these malignancies, from the precursor cystitis glandularis, which is caused by chronic irritation and inflammation of exposed mucosa of the exstrophic bladder. Squamous cell carcinoma and rhabdomyosarcoma have also been reported.

Adenocarcinoma may develop adjacent to the ureterointestinal anastomosis in patients with urinary diversions that mix the urinary and fecal streams. This malignancy was reported in more than 10% of patients in one series 25. Patients younger than 25 years with ureterosigmoidostomy have a 7000-fold greater risk of adenocarcinoma of the colon than the general population (mean latency, 10 years).

Complications of short-gut syndrome are as follows:

  • Paucity of hindgut and, in many cases, limited small intestine can result in electrolyte abnormalities in patients with cloacal exstrophy
  • Dehydration is particularly a concern during an acute GI illness with diarrhea
  • Nutritional supplementation may be required

Cloacal exstrophy prognosis

Surgical techniques to treat cloacal exstrophy have improved dramatically in recent years, which means 90% to 100% of babies survive after surgery. Their quality of life and degree of need for ongoing care vary from case to case.

Mortality with classic bladder exstrophy or epispadias is rare. Historically, cloacal exstrophy was associated with significant mortality. Reconstruction was not attempted until the 1970s. Advances in the care of critically ill neonates and recognition of the importance of early parenteral nutritional support have allowed successful reconstruction and survival of children with cloacal exstrophy.

Survival rates after surgical treatment are excellent. With respect to bladder function or continence, reports vary according to the type of reconstruction performed 26. Objective and subjective evidence indicates that many exstrophic bladders do not function normally after reconstruction and may deteriorate over time.

Continence rates of 75-90% have been reported after staged reconstruction in classic exstrophy, but more than one continence procedure may be required (eg, bladder neck reconstruction, bladder augmentation, bladder neck sling, or artificial urinary sphincter). Many of these patients require clean intermittent catheterization (CIC) through the urethra or a continent stoma because they are unable to void spontaneously to completion. Less encouraging results also are reported.

Continence results after staged reconstruction are poor (< 25%) in cloacal exstrophy because of abnormal bladder innervation in many patients. Experience with rectal reservoirs (ureterosigmoidostomy and variants) for exstrophy continence demonstrates rates higher than 95%, but they present long-term malignancy risks 27. Continent reconstruction with intestinal bladder augmentation and clean intermittent catheterization has a success rate greater than 90%.

With regard to psychosocial concerns, education, employment, and social relationships generally are not affected substantially in adults with a history of bladder exstrophy and epispadias 28. Age-appropriate adaptive behaviors may be delayed in children with chronic medical conditions 29. One study revealed below-average daily living skills and socialization but above-average self-esteem. Children may need support in disclosing their condition to new peers.

Multiple anomalies associated with cloacal exstrophy can have a significant impact on daily life. Patients are affected by permanent colostomy, the need for clean intermittent catheterization, and impaired ambulation.

Diet

Some young patients with cloacal exstrophy are seriously affected by short-gut syndrome and may depend on long-term supplemental parenteral nutrition for growth and development.

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  3. Clements MB, Chalmers DJ, Meyers ML, Vemulakonda VM. Prenatal diagnosis of cloacal exstrophy: a case report and review of the literature. Urology. 2014;83(5):1162-1164. doi:10.1016/j.urology.2013.10.050[]
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  10. Wood HM, Babineau D, Gearhart JP. In vitro fertilization and the cloacal/bladder exstrophy-epispadias complex: a continuing association. J Pediatr Urol. 2007 Aug. 3 (4):305-10.[]
  11. Maruf M, Benz K, Jayman J, Kasprenski M, Michaud J, Di Carlo HN, et al. Variant Presentations of the Exstrophy-Epispadias Complex: A 40-Year Experience. Urology. 2018 Dec 18.[]
  12. Bhatnagar V. Bladder exstrophy: An overview of the surgical management. J Indian Assoc Pediatr Surg. 2011 Jul. 16 (3):81-7.[]
  13. Baird AD, Nelson CP, Gearhart JP. Modern staged repair of bladder exstrophy: a contemporary series. J Pediatr Urol. 2007 Aug. 3 (4):311-5.[]
  14. Chua ME, Ming JM, Fernandez N, Varghese A, Farhat WA, Bagli DJ, et al. Modified staged repair of bladder exstrophy: a strategy to prevent penile ischemia while maintaining advantage of the complete primary repair of bladder exstrophy. J Pediatr Urol. 2018 Sep 25.[]
  15. Ben-Chaim J, Hidas G, Wikenheiser J, Landau EH, Wehbi E, Kelly MS, et al. Kelly procedure for exstrophy or epispadias patients: Anatomical description of the pudendal neurovasculature. J Pediatr Urol. 2016 Jun. 12 (3):173.e1-6.[]
  16. Leclair MD, Faraj S, Sultan S, Audry G, Héloury Y, Kelly JH, et al. One-stage combined delayed bladder closure with Kelly radical soft-tissue mobilization in bladder exstrophy: preliminary results. J Pediatr Urol. 2018 Dec. 14 (6):558-564.[]
  17. Anwar AZ, Mohamed MA, Hussein A, Shaaban AM. Modified penile disassembly technique for boys with epispadias and those undergoing complete primary repair of exstrophy: long-term outcomes. Int J Urol. 2014 Sep. 21 (9):936-40.[]
  18. Ko JS, Lue K, Friedlander D, Baumgartner T, Stuhldreher P, DiCarlo HN, et al. Cystectomy in the Pediatric Exstrophy Population: Indications and Outcomes. Urology. 2018 Jun. 116:168-171.[]
  19. Levitt MA, Mak GZ, Falcone RA Jr, Peña A. Cloacal exstrophy–pull-through or permanent stoma? A review of 53 patients. J Pediatr Surg. 2008 Jan. 43 (1):164-8; discussion 168-70.[]
  20. Mathews R, Gearhart JP, Bhatnagar R, Sponseller P. Staged pelvic closure of extreme pubic diastasis in the exstrophy-epispadias complex. J Urol. 2006 Nov. 176 (5):2196-8.[]
  21. Inouye BM, Tourchi A, Di Carlo HN, Young EE, Mhlanga J, Ko JS, et al. Safety and efficacy of staged pelvic osteotomies in the modern treatment of cloacal exstrophy. J Pediatr Urol. 2014 Dec. 10 (6):1244-8.[]
  22. Houk CP, Lee PA. Consensus statement on terminology and management: disorders of sex development. Sex Dev. 2008. 2 (4-5):172-80.[]
  23. Shnorhavorian M, Grady RW, Andersen A, Joyner BD, Mitchell ME. Long-term followup of complete primary repair of exstrophy: the Seattle experience. J Urol. 2008 Oct. 180 (4 Suppl):1615-9; discussion 1619-20.[]
  24. Schaeffer AJ, Purves JT, King JA, Sponseller PD, Jeffs RD, Gearhart JP. Complications of primary closure of classic bladder exstrophy. J Urol. 2008 Oct. 180 (4 Suppl):1671-4; discussion 1674.[]
  25. Krishnamsetty RM, Rao MK, Hines CR, Saikaly EP, Corpus RP, DeBandi HO. Adenocarcinoma in exstrophy and defunctional ureterosigmoidostomy. J Ky Med Assoc. 1988 Aug. 86 (8):409-14.[]
  26. Kibar Y, Roth C, Frimberger D, Kropp BP. Long-term results of penile disassembly technique for correction of epispadias. Urology. 2009 Mar. 73 (3):510-4.[]
  27. Husmann DA, Rathbun SR. Long-term follow up of enteric bladder augmentations: the risk for malignancy. J Pediatr Urol. 2008 Oct. 4 (5):381-5; discussion 386.[]
  28. Mukherjee B, McCauley E, Hanford RB, Aalsma M, Anderson AM. Psychopathology, psychosocial, gender and cognitive outcomes in patients with cloacal exstrophy. J Urol. 2007 Aug. 178 (2):630-5; discussion 634-5.[]
  29. Ebert A, Scheuering S, Schott G, Roesch WH. Psychosocial and psychosexual development in childhood and adolescence within the exstrophy-epispadias complex. J Urol. 2005 Sep. 174 (3):1094-8.[]
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BladderKidneysProceduresUretersUrethraUrinary System

Uroflowmetry

Uroflowmetry

Uroflowmetry

Uroflowmetry is a simple, diagnostic screening procedure used to measures the flow rate of urine over time (urine speed and urine volume). Uroflowmetry tracks how fast urine flows, how much flows out, and how long it takes. It’s a diagnostic test to assess how well your urinary tract functions. Your doctor may suggest uroflowmetry if you have trouble urinating, or have a slow stream. Uroflowmetry test is noninvasive (the skin is not pierced), and may be used to assess bladder and sphincter function. Uroflowmetry measurements are performed in a health care provider’s office; no anesthesia is needed.

By measuring the average and top rates of urine flow, this test can show an obstruction in your urinary tract such as an enlarged prostate. When combined with the cystometrogram, uroflowmetry can help find problems like a weak bladder.

For uroflowmetry test, you should arrive at the doctor’s office with a fairly full bladder. If possible, do not urinate for a few hours before the test.

You will be asked to urinate privately into a special toilet that has a container for collecting the urine and a scale or a funnel connected to the electronic uroflowmeter. The equipment creates a graph that shows changes in urine flow rate from second to second so your doctor can see when the flow rate is the highest and how many seconds it takes to get there. This records information about your urine flow on a flow chart. The flow rate is calculated as milliliters (ml) of urine passed per second. Both average and top flow rates are measured.

Results of this test will be abnormal if the bladder muscles are weak or urine flow is blocked. Another approach to measuring flow rate is to record the time it takes to urinate into a special container that accurately measures the volume of urine.

Common urine flow patterns:

  • Flow rate (Q): Volume of fluid expelled via the urethra per unit time (mL/s).
  • Voided volume (Vvoid): Total volume expelled via the urethra (mL).
  • Average flow rate (Qave): Voided volume divided by the flow time.
  • Maximum flow rate (Qmax): Maximum measured value of the flow rate after correction for artefacts.
  • Voiding time: Total duration of micturition (second).
  • Flow time: Time over which measurable flow actually occurs.
  • Time to maximum flow: Elapsed time from onset of flow to maximum flow.

The fastest flow rate, also known as maximum flow rate (Qmax), is used to understand if a block or obstruction is severe.

Your doctor will know your test results right away. Average results are based on your age and sex.

  • Typically, urine flow rate from 10 ml to 21 ml per second. Women range closer to 15 ml to 18 ml per second.
  • A slow or low flow rate may mean there is an obstruction at the bladder neck or in the urethra, an enlarged prostate, or a weak bladder.
  • A fast or high flow rate may mean there are weak muscles around the urethra, or urinary incontinence problems.

You may be asked to take other tests to fully learn what’s going on for treatment. Your urologist will create a treatment plan based on test results and your health history.

Facts about urine:

  • Adults pass about a quart and a half of urine each day, depending on the fluids and foods consumed.
  • The volume of urine formed at night is about half that formed in the daytime.
  • Normal urine is sterile. It contains fluids, salts, and waste products, but it is free of bacteria, viruses, and fungi.
  • The tissues of the bladder are isolated from urine and toxic substances by a coating that discourages bacteria from attaching and growing on the bladder wall.

Figure 1. Uroflowmetry

Uroflowmetry

How does the urinary system work?

The body takes nutrients from food and converts them to energy. After the body has taken the food components that it needs, waste products are left behind in the bowel and in the blood.

The urinary system helps the body to eliminate liquid waste called urea and keeps the chemicals, such as potassium and sodium, and water in balance. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys, where it is removed along with water and other wastes in the form of urine.

Urinary system parts and their functions:

  • Two kidneys. This pair of purplish-brown organs is located below the ribs toward the middle of the back. Their function is to remove liquid waste from the blood in the form of urine, keep a stable balance of salts and other substances in the blood, and produce erythropoietin, a hormone that aids the formation of red blood cells. The kidneys also help to regulate blood pressure. The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.
  • Two ureters. These narrow tubes that carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters.
  • Bladder. This triangle-shaped, hollow organ is located in the lower abdomen. It is held in place by ligaments that are attached to other organs and the pelvic bones. The bladder’s walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can store up to two cups of urine for two to five hours.
  • Two sphincter muscles. These circular muscles help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder
  • Nerves in the bladder. The nerves alert a person when it is time to urinate, or empty the bladder
  • Urethra. This tube allows urine to pass outside the body

Figure 2. Urinary system and anatomy

Urinary system anatomy

urinary tract system

Reasons for the uroflowmetry test

Uroflowmetry is a quick, simple diagnostic screening test that provides valuable feedback about the health of the lower urinary tract. It is commonly performed to determine if there is obstruction to normal urine outflow. Medical conditions that can alter the normal flow of urine include, but are not limited to, the following:

  • Benign prostatic hypertrophy. A benign enlargement of the prostate gland that usually occurs in men over age 50. Enlargement of the prostate interferes with normal passage of urine from the bladder. If left untreated, the enlarged prostate can obstruct the bladder completely.
  • Cancer of the prostate, or bladder tumor.
  • Urinary incontinence. Involuntary release of urine from the bladder.
  • Urinary blockage. Obstruction of the urinary tract can occur for many reasons along any part of the urinary tract from kidneys to urethra. Urinary obstruction can lead to a backflow of urine causing infection, scarring, or kidney failure if untreated.
  • Neurogenic bladder dysfunction. Improper function of the bladder due to an alteration in the nervous system, such as a spinal cord lesion or injury.
  • Frequent urinary tract infections.

Uroflowmetry may be performed in conjunction with other diagnostic procedures, such as cystometry, cystography, retrograde cystography, and cystoscopy.

There may be other reasons for your doctor to recommend uroflowmetry.

Urine flow rate test

Uroflowmetry is performed by having a person urinate into a special funnel that is connected to a measuring instrument. The measuring instrument calculates the amount of urine, rate of flow in seconds, and length of time until completion of the void. This information is converted into a graph and interpreted by a doctor. The information helps evaluate function of the lower urinary tract or help determine if there is an obstruction of normal urine outflow.

During normal urination, the initial urine stream starts slowly, but almost immediately speeds up until the bladder is nearly empty. The urine flow then slows again until the bladder is empty. In persons with a urinary tract obstruction, this pattern of flow is altered, and increases and decreases more gradually. The uroflowmeter graphs this information, taking into account the person’s gender and age. Depending on the results of the procedure, other tests may be recommended by your doctor.

Other related procedures that may be used to diagnose urinary outflow obstruction or lower urinary tract dysfunction include cystometry, cystography, retrograde cystography, and cystoscopy.

Before the urology flow rate test

  • Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
  • Generally, no prior preparation, such as fasting or sedation, is required.
  • You may be instructed to drink about four glasses of water several hours before the test is performed to ensure that your bladder is full. In addition, you should not empty your bladder before arriving for the procedure.
  • If you are pregnant or suspect that you are pregnant, you should notify your doctor.
  • Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking.
  • Based on your medical condition, your doctor may request other specific preparation.

During the urology flow rate test

Uroflowmetry may be performed on an outpatient basis or as part of your stay in the hospital. Procedures may vary depending on your condition and your doctor’s practices.

Generally, uroflowmetry follows this process:

  1. You will be taken into the procedure area and instructed how to use the uroflowmetry device.
  2. When you are ready to urinate, you will press the flowmeter start button and count for five seconds before beginning urination.
  3. You will begin to urinate into the funnel device that is attached to the regular commode. The flowmeter will record information as you are urinating.
  4. You should not push or strain as you urinate. You should remain as still as possible.
  5. When you have finished urinating, you will count for five seconds and press the flowmeter button again.
  6. You should not put any toilet paper into the funnel device.
  7. The procedure will be concluded at this point. Depending on your specific medical condition, you may be asked to perform the test on several consecutive days.

After the urology flow rate test

Generally, there is no special type of care following uroflowmetry. However, your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

Uroflowmetry normal flow

There is great variation in uroflowmetry parameters even in the non‐symptomatic population 1, although flow curves are generally repeatable for the same patient. In particular, there are no definitive ‘normal’ ranges for maximum flow rate (Qmax), although it decreases with age and voided volume (but not in a directly proportional manner). Males aged <40 years usually have a Qmax of >25 mL/s, and females usually have a Qmax of 5–10 mL/s more than males at a given bladder volume. Beware the ‘normal flow’ that in fact represents the effect of a compensatory increase in the voiding pressure generated by the detrusor in patients with bladder outlet obstruction 2.

Decreased urine flow

This is the most common abnormal flow trace seen in practice and is represented by a dampened curve with decreased Qmax and prolonged flow time. A significantly decreased Qmax (generally accepted as <15 mL/s) cannot be used to distinguish between BOO in men, outflow obstruction in women, and impaired detrusor contractility 6; in appropriate cases, formal multichannel urodynamic studies with concomitant measurements of flow and detrusor pressures are important to delineate between these conditions.

Despite the limitations, Qmax remains the single best non‐invasive urodynamic test to detect possible lower urinary tract obstruction. The test is also useful in some clinical situations to guide further evaluation to predict outcome after surgery and for preoperative counseling:

  • Males with a Qmax above the threshold value of 15 mL/s (or 12 mL/s) 3 may have a poorer outcome after prostate surgery for presumed bladder outlet obstruction 4 and these men should be considered for formal urodynamics to arrive at a definite diagnosis and decrease treatment failures.
  • Females undergoing mid‐urethral sling surgery with a Qmax of <15 mL/s at preoperative uroflowmetry are more likely to fail a trial of void after sling surgery 5.

Plateau urine flow

A long flow time, associated with a poor flow is typical of a stricture in the lower urinary tract. Another commonly encountered scenario is the patient with post‐radical prostatectomy incontinence. One should suspect an anastomotic stricture if this flow curve pattern is seen in the office during initial postoperative assessment. The patient should be considered for a cystoscopy with a view to treat the stricture as the next step in management, rather than referral for a formal urodynamic study as difficult catheterisation is commonly encountered.

Intermittent urine flow

This may be seen in patients who void with some abdominal straining due to bladder outlet obstruction or a poorly contractile detrusor, and is often superimposed on a decreased or plateauing curve pattern.

‘Saw‐tooth’ urine flow

Often pathogneumonic of detrusor‐sphincter‐dyssynergia, this curve should prompt urgent pressure‐flow studies to investigate high intravesical pressures that might damage the upper tracts.

‘Super‐voider’

This is seen after surgery for bladder outlet obstruction (e.g. TURP or urethroplasty), in patients with decreased urethral resistance (e.g. intrinsic urethral sphincter deficiency), or occasionally in those with detrusor overactivity. It may be considered ‘normal’ if there are no symptoms or signs to suggest underlying pathology, and is sometimes seen in young healthy female patients who may have a Qmax exceeding 40 mL/s.

‘Kicking the bucket’, and other artefacts

Urologists must be wary of artefacts and always compare the automated printout reading with the curve and clinical context. Smooth muscle physiology suggests that there should not be any abrupt spikes on a trace. A patient who accidentally kicks the flowmeter can appear to have a ‘normal’ Qmax. Other artefacts created by abdominal straining, squeezing the prepuce, or even variations in the direction of the urinary stream (within the funnel of the uroflowmeter) are common and urologists must recognise these.

Uroflowmetry procedure risks

Because uroflowmetry is a noninvasive procedure, it is safe for most persons. The test is usually done in privacy to ensure that the person voids in a natural setting.

There may be risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Certain factors or conditions may interfere with the accuracy of uroflowmetry. These factors include, but are not limited to, the following:

  • Straining with urination
  • Body movement during urination
  • Certain medications that affect bladder and sphincter muscle tone
  1. Wyndaele JJ. Normality in urodynamics studied in healthy adults. J Urology 1999; 161: 899–902.[]
  2. Jarvis, T.R., Chan, L. and Tse, V. (2012), PRACTICAL UROFLOWMETRY. BJU Int, 110: 28-29. doi:10.1111/bju.11617[]
  3. McLoughlin J, Gill KP, Abel PD, Williams G. Symptoms versus flow rates versus urodynamics in the selection of patients for prostatectomy. Br J Urol 1990; 66: 303–305.[]
  4. Jensen KM, Jorgensen JB, Mogensen P. Urodynamics in prostatism. I. Prognostic value of uroflowmetry. Scand J Urol Nephrol 1988; 22: 109–117.[]
  5. Wheeler TL, Richter HE, Greer WJ, Bowling CB, Redden DT, Varner RE. Predictors of success with postoperative voiding trials after a mid‐urethral sling procedure. J Urol 2008; 179: 600–604.[]
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UrethraUrinary System

Urethra

urethra – male and female

What is a urethra

The urethra is a thin-walled tube that drains urine from the bladder. In both males and females, the urethra is the terminal portion of the urinary system and the passageway for discharging urine from the body. In males, it discharges semen (fluid that contains sperm) as well (Figure 1 and 2). This tube consists of smooth muscle and an inner mucosa.

In males, the muscle layer becomes very thin toward the distal end of the urethra. The lining epithelium changes from a transitional epithelium near the bladder to a stratified and pseudostratified columnar epithelium in mid-urethra (sparse in females), and then to a stratified squamous epithelium near the end of the urethra.

At the bladder-urethra junction, a thickening of the detrusor forms the internal urethral sphincter. This is an involuntary sphincter of smooth muscle that keeps the urethra closed when urine is not being passed and prevents dribbling of urine between voidings. A second sphincter, the external urethral sphincter, surrounds the urethra within the sheet of muscle called the urogenital diaphragm. This external sphincter is a skeletal muscle used to inhibit urination voluntarily until the proper time. The levator ani muscle of the pelvic floor also serves as a voluntary constrictor of the urethra.

The length and functions of the urethra differ in the two sexes. In females, the urethra is just 3–4 cm (1.5 inches) long and is bound to the anterior wall of the vagina by connective tissue (see Figure 2). It opens to the outside at the external urethral orifice, a small, often difficult-to-locate opening that lies anterior to the vaginal opening and posterior to the clitoris.

Male urethra

In males, the urethra is about 20 cm long (8 inches) and has three named regions: the prostatic urethra, which is about 2.5 cm long and runs in the prostate; the intermediate part of the urethra, or membranous urethra, which runs for about 2.5 cm through the membrane like urogenital diaphragm; and the spongy urethra, which is about 15 cm long, passes through the entire penis, and opens at the tip of the penis via the external urethral orifice. The male urethra carries ejaculating semen as well as urine (although not simultaneously) from the body.

The muscularis of the prostatic urethra is composed of mostly circular smooth muscle fibers superficial to the lamina propria; these circular fibers help form the internal urethral sphincter of the urinary bladder. The muscularis of the intermediate (membranous) urethra consists of circularly arranged skeletal muscle fibers of the deep muscles of the perineum that help form the external urethral sphincter of the urinary bladder.

Several glands and other structures associated with reproduction deliver their contents into the male urethra (see Figure 1). The prostatic urethra contains the openings of (1) ducts that transport secretions from the prostate and (2) the seminal vesicles and ductus (vas) deferens, which deliver sperm into the urethra and provide secretions that both neutralize the acidity of the female reproductive tract and contribute to sperm motility and viability. The openings of the ducts of the bulbourethral glands or Cowper’s glands empty into the spongy urethra. They deliver an alkaline substance prior to ejaculation that neutralizes the acidity of the urethra. The glands also secrete mucus, which lubricates the end of the penis during sexual arousal. Throughout the urethra, but especially in the spongy urethra, the openings of the ducts of urethral glands or Littré glands discharge mucus during sexual arousal and ejaculation.

Female urethra

In females, the urethra lies directly posterior to the pubic symphysis; is directed obliquely, inferiorly, and anteriorly; and has a length of 4 cm (1.5 in.). The opening of the urethra to the exterior, the external urethral orifice, is located between the clitoris and the vaginal opening. The wall of the female urethra consists of a deep mucosa and a superficial muscularis. The mucosa is a mucous membrane composed of epithelium and lamina propria (areolar connective tissue with elastic fibers and a plexus of veins). Near the urinary bladder, the mucosa contains transitional epithelium that is continuous with that of the urinary bladder; near the external urethral orifice, the epithelium is nonkeratinized stratified squamous epithelium. Between these areas, the mucosa contains stratified columnar or pseudostratified columnar epithelium. The muscularis consists of circularly arranged smooth muscle fibers and is continuous with that of the urinary bladder.

Figure 1. Male and Female Urethra

urethra

Figure 2. Male and Female Urethra – Location

 

male and female urethra location

Urethra function

Drainage tube that transports stored urine from body.

And in men the urethra also carries ejaculating semen as well as urine (although not simultaneously) from the body.

Burning, swollen and itchy urethra

Urethritis is infection (swelling and irritation) of the urethra 1.

Bacteria, including those that are sexually transmitted, are the most common cause of urethritis.

Symptoms include pain while urinating, a frequent or urgent need to urinate, and sometimes a discharge.

Risks for urethritis include 2:

  • Being a female
  • Being male, ages 20 to 35
  • Having many sexual partners
  • High-risk sexual behavior (such as anal sex without a condom)
  • History of sexually transmitted diseases

Antibiotics are usually given to treat the infection.

Causes of Urethritis

Urethritis may be caused by bacteria, fungi, or viruses (for example, herpes simplex virus).

Sexually transmitted diseases are common causes of urethritis. Organisms—such as Neisseria gonorrhoeae, which causes gonorrhea—can spread to the urethra during sexual intercourse with an infected partner. Chlamydia and the herpes simplex virus are also commonly transmitted sexually and can cause urethritis. When men develop urethritis, the gonorrheal organism is a very common cause. Although this organism may infect the urethra in women, the vagina, cervix, uterus, ovaries, and fallopian tubes are more likely to be infected. Trichomonas, a type of microscopic parasite, also causes urethritis in men. Urethritis may also be caused by the bacteria that commonly cause other urinary tract infections, such as Escherichia coli.

Symptoms of Urethritis

In both men and women, there is usually pain during urination and a frequent, urgent need to urinate. Sometimes people have no symptoms. In men, when gonorrhea or chlamydia is the cause, there is usually a discharge from the urethra. The discharge is often yellowish green and thick when the gonococcal organism is involved and may be clear and thinner when other organisms are involved. In women, discharge is less common.

In men:

  • Blood in the urine or semen
  • Burning pain while urinating (dysuria)
  • Discharge from penis
  • Fever (rare)
  • Frequent or urgent urination
  • Itching, tenderness, or swelling in penis
  • Enlarged lymph nodes in the groin area
  • Pain with intercourse or ejaculation

In women:

  • Abdominal pain
  • Burning pain while urinating
  • Fever and chills
  • Frequent or urgent urination
  • Pelvic pain
  • Pain with intercourse
  • Vaginal discharge

Other disorders that cause pain during urination include bladder infection and vaginitis (inflammation of the vagina).

Complications of Urethritis

Infections of the urethra that are not treated or are inadequately treated may cause a narrowing (stricture) of the urethra. A stricture increases the risk that infections will develop in the bladder or the kidneys. Untreated gonorrhea rarely leads to an accumulation of pus (abscess) around the urethra. An abscess can cause outpouchings from the urethral wall (urethral diverticula), which can also become infected. If the abscess perforates the skin, the vagina, or the rectum, urine may flow through a newly created abnormal connection (urethral fistula).

Diagnosis of Urethritis

The health care provider will examine you.

In men, the exam will include the abdomen, bladder area, penis, and scrotum. The physical exam may show:

  • Discharge from the penis
  • Tender and enlarged lymph nodes in the groin area
  • Tender and swollen penis

A digital rectal exam will also be performed.

Women will have abdominal and pelvic exams. The provider will check for:

  • Discharge from the urethra
  • Tenderness of the lower abdomen
  • Tenderness of the urethra

Your provider may look into your bladder using a tube with a camera on the end. This is called cystoscopy.

The following tests may be done:

  • Complete blood count (CBC)
  • C-reactive protein test
  • Pelvic ultrasound (women only)
  • Pregnancy test (women only)
  • Urinalysis and urine cultures
  • Tests for gonorrhea, chlamydia, and other sexually transmitted illnesses (STI)
  • Urethral swab

Doctors can usually make a diagnosis of urethritis based on the symptoms and examination. A sample of the discharge, if present, is collected by inserting a soft-tipped swab into the end of the urethra. The urethral swab is then sent to a laboratory for analysis so that the infecting organism can be identified.

Treatment of Urethritis

The goals of treatment are to 3:

  • Get rid of the cause of infection
  • Improve symptoms
  • Prevent the spread of infection

If you have a bacterial infection, you will be given antibiotics. Antivirals for herpes simplex.

You may take pain relievers, urinary pain reliever along with antibiotics.

People with urethritis who are being treated should avoid sex, or use condoms during sex. Your sexual partner must also be treated if the condition is caused by an infection.

Urethritis caused by trauma or chemical irritants is treated by avoiding the source of injury or irritation.

Urethritis that does not clear up after antibiotic treatment and lasts for at least 6 weeks is called chronic urethritis. Different antibiotics may be used to treat this problem.

For sexually transmitted infections, treatment of partners with antibiotics.

Sexually transmitted diseases that cause urethritis may be prevented by using a condom.

Treatment depends on the cause of the infection. However, identification of the organism causing urethritis can take days. Thus, doctors usually begin treatment with antibiotics that cure the most common causes. For sexually active men, treatment is usually with a ceftriaxone injection for gonorrhea plus oral azithromycin or oral doxycycline for chlamydia 4. If tests exclude the possibility of gonorrhea and chlamydia, trimethoprim/sulfamethoxazole or a fluoroquinolone antibiotic (such as ciprofloxacin) may be used. Women may be treated as if they had cystitis. An antiviral drug, such as acyclovir, may be needed for a herpes simplex infection. If the cause is suspected to be a sexually transmitted disease, the person’s sex partners should be evaluated for treatment. Men who receive a diagnosis of urethritis should be tested for HIV and syphilis.

Prevention of urethritis

Things you can do to help avoid urethritis include:

  • Keep the area around the opening of the urethra clean.
  • Follow safer sex practices. Have one sexual partner only (monogamy) and use condoms.

Outlook (Prognosis) for urethritis

With the correct diagnosis and treatment, urethritis most often clears up without further problems.

However, urethritis can lead to long-term damage to the urethra and scar tissue called urethral stricture. It can also cause damage to other urinary organs in both men and women. In women, the infection could lead to fertility problems if it spreads to the pelvis.

Possible Complications of urethritis

Men with urethritis are at risk for the following:

  • Bladder infection (cystitis)
  • Epididymitis
  • Infection in the testicles (orchitis)
  • Prostate infection (prostatitis)

After a severe infection, the urethra may become scarred and then narrowed.

Women with urethritis are at risk for the following:

  • Bladder infection (cystitis)
  • Cervicitis
  • Pelvic inflammatory disease (PID — an infection of the uterus lining, uterine (fallopian) tubes, or ovaries)

What is Narrow urethra

Narrow urethra also called urethral stricture, involves scarring that narrows the urethra tube that carries urine out of your body 5. A stricture restricts the flow of urine from the bladder and can cause a variety of medical problems in the urinary tract, including inflammation or infection.

Congenital (present at birth) urethral stricture may manifest similarly to urethral valves and may be diagnosed by prenatal ultrasonography, or postnatally by symptoms and signs of outlet obstruction or patent urachus and is confirmed by retrograde urethrography. Initial management is often with endoscopic urethrotomy, although open urethroplasty may be necessary.

Scar tissue, which can narrow the urethra, can be due to:

  • A medical procedure that involves inserting an instrument, such as an endoscope, into the urethra
  • Intermittent or long-term use of a tube inserted through the urethra to drain the bladder (catheter)
  • Trauma or injury to the urethra or pelvis
  • An enlarged prostate or previous surgery to remove or reduce an enlarged prostate gland
  • Cancer of the urethra or prostate
  • Sexually transmitted infections
  • Radiation therapy

Urethral stricture is much more common in males than in females. Often the cause is unknown.

Signs and symptoms of urethral stricture include:

  • Decreased urine stream
  • Incomplete bladder emptying
  • Spraying of the urine stream
  • Difficulty, straining or pain when urinating
  • Increased urge to urinate or more-frequent urination
  • Urinary tract infection.

Urethral valves

In boys, folds in the posterior urethra may act as valves impairing urine flow. Urologic sequelae of urethral valves include urinary hesitancy, decreased urinary stream, urinary tract infection (UTI), overflow incontinence, myogenic bladder malfunction, vesicoureteral reflux, upper urinary tract damage, and renal insufficiency. The valves occasionally occur with a patent urachus. Because fetal urine excretion contributes to the amniotic fluid, severe urethral obstruction can cause decreased amniotic fluid (oligohydramnios), which can cause lung hypoplasia and consequent pulmonary hypertension, pulmonary hypoplasia, and/or respiratory failure. Pulmonary hypertension can then cause systemic hypertension. Severe cases may result in perinatal demise.

Diagnosis is often made by findings on routine prenatal ultrasonography, including severe bilateral hydroureteronephrosis or oligohydramnios. Cases suspected postnatally (often because of history of an abnormal urine stream) are confirmed by immediate voiding cystourethrography.

Surgery (usually via endoscopy) is done at time of diagnosis to prevent progressive renal deterioration.

A much less common anomaly, diverticulum of the anterior urethra, may act as a valve (anterior urethral valve) and is also treated endoscopically.

Urethral Dilation

Urethral dilation is used to treat the following:

  • Urethral strictures
  • Meatal stenosis

Contraindications include untreated infection and bleeding diathesis. Dilation can be done using various techniques, such as by inflating a balloon or by inserting progressively larger instruments called sounds. Usually, lidocaine gel, a local anesthetic, is first introduced into the penis. Typically, after dilation a urethral catheter is left in place temporarily to facilitate healing. Sometimes patients are asked to insert an instrument into their own urethra periodically at home.

Urethra stretching

Urethral dilatation has been advocated as empirical treatment for adult women with lower urinary tract complaints for long time. The discovery of a distal urethral ring by Lyon and associates led to the hypothesis that urethral stenosis was the cause of recurrent urinary tract infections (UTIs) and dysfunctional voiding in girls 6. It was postulated that rupture of this ring by dilatation would relieve the obstruction. Kerr and associates decided on cutting this contraction ring with the otis urethrotome rather than dilating it with sounds 7. At the same time, they extended this procedure to include adult female patients.

Although reviewing the literature reveals little solid evidence regarding the theoretical basis of this practice, several reports suggest that urologists are still practising urethral dilatation as treatment for women with lower urinary tract complaints that are not efficiently managed by other means 8.

Urethral stenosis is the most common chosen indication (97%) for urethral dilatation. Lower urinary tract symptoms with inadequate bladder emptying was the second most common indication (72%). Some 65% of urologists chose to use dilatation for urethral syndrome, 49% for idiopathic acute urinary retention when trail without a catheter fails, while 35% used it for chronic urinary retention. The majority of urologists (69%) indicated that less than 25% of their patients had evidence of stenosis. Of urologists, 55% believed that less than half of their patients experienced long-term improvement, while 45% thought that the improvement was experienced in more than 50% of cases.

Overall, 54% reported that repeated dilatation was required in less than 25%, while one-third of urologists considered repeating the procedure in up to half of the cases. Most urologists perform this procedure only under general anaesthesia (90%), while 7% always use local anaesthesia; 18% perform dilatation under either local or general anaesthesia depending on patient’s condition. Three consultants said that spinal anaesthesia is one of their options, and one consultant used peri-urethral infiltration. Most urologists tend to dilate up to 32 F (45%), while only 9% dilated beyond 36 F. Four consultants used different sizes of Hegar dilators.

There was a lack of uniformity about the size to which urologists dilated the urethra, although it appears that most dilated to 32 Fr. This is consistent with previous studies that showed a surprising dearth of information about the range of urethral calibre that is found in normal healthy women. The tendency to repeat dilatation among some urologists might suggest that urethral dilatation is a small price to pay for a possible relief of symptoms, where there are few, if any, sequelae.

In conclusion, there is little scientific data to support the empirical use of urethral dilatation in women 8. Nonetheless, despite the lack of such data, many urologists continue to find it a useful tool in approaching women with lower urinary tract complaints. Why the perception that urethral dilatation is an effective procedure exists among some urologists and is absent among others is a matter of debate. Obviously, differences in training and personal experience will affect an individual’s practice patterns. Prospective studies with readily definable outcome measures are needed. Until that is done, the presumed beneficial effect of urethral dilatation will remain merely anecdotal 8.

Benign prostatic hyperplasia

Benign prostatic hyperplasia—also called BPH—is a condition in men in which the prostate gland is enlarged and not cancerous. Benign prostatic hyperplasia is also called benign prostatic hypertrophy or benign prostatic obstruction.

Severe benign prostatic hypertrophy can cause serious problems over time, such as urinary tract infections, and bladder or kidney damage. If it is found early, you are less likely to develop these problems.

The complications of benign prostatic hyperplasia may include 9:

  • acute urinary retention
  • chronic, or long lasting, urinary retention
  • blood in the urine
  • urinary tract infections (UTIs)
  • bladder damage
  • kidney damage
  • bladder stones

Most men with benign prostatic hyperplasia do not develop these complications. However, kidney damage in particular can be a serious health threat when it occurs.

A health care provider treats benign prostatic hyperplasia based on the severity of symptoms, how much the symptoms affect a man’s daily life, and a man’s preferences.

Men may not need treatment for a mildly enlarged prostate unless their symptoms are bothersome and affecting their quality of life. In these cases, instead of treatment, a urologist may recommend regular checkups. If benign prostatic hyperplasia symptoms become bothersome or present a health risk, a urologist most often recommends treatment.

Prostatic stent insertion. This procedure involves a urologist inserting a small device called a prostatic stent through the urethra to the area narrowed by the enlarged prostate. Once in place, the stent expands like a spring, and it pushes back the prostate tissue, widening the urethra. Prostatic stents may be temporary or permanent. Urologists generally use prostatic stents in men who may not tolerate or be suitable for other procedures.

  1. Urethritis. Merck Manual. http://www.merckmanuals.com/home/kidney-and-urinary-tract-disorders/urinary-tract-infections-uti/urethritis[]
  2. Urethritis. Medline Plus. https://medlineplus.gov/ency/article/000439.htm[]
  3. Augenbraun MH, McCormack WM. Urethritis. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, Updated Edition. 8th ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 109.[]
  4. Swygard H, Cohen MS. Approach to the patient with a sexually transmitted disease. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 285.[]
  5. Urethral stricture. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/urethral-stricture/symptoms-causes/syc-20362330[]
  6. DISTAL URETHRAL STENOSIS IN LITTLE GIRLS. LYON RP, TANAGHO EA. J Urol. 1965 Mar; 93():379-88. https://www.ncbi.nlm.nih.gov/pubmed/14265182/[]
  7. Kerr WS, Leadbetter GW, Donahue J. An evaluation of internal urethrotomy in female patients with urethral or bladder neck obstruction. J Urol. 1966;95:218–20.[]
  8. Masarani M, Willis R. Urethral Dilatation in Women: Urologists’ Practice Patterns in the UK. Annals of The Royal College of Surgeons of England. 2006;88(5):496-498. doi:10.1308/003588406X114884. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1964673/[][][]
  9. Prostate Enlargement (Benign Prostatic Hyperplasia). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-problems/prostate-enlargement-benign-prostatic-hyperplasia[]
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UretersUrethraUrinary System

Ureter

Microscopic structure of the ureter

What is ureter

The ureters are slender tubes, about 25 cm (10 inches) long, that carry urine from the kidneys to the bladder (see Figure 1). Each ureter begins superiorly, at the level of lumbar spine L2, as a continuation of the renal pelvis (see Figure 2). From there, it descends retroperitoneal through the abdomen, enters the true pelvis by crossing the pelvic brim at the sacroiliac joint, enters the posterolateral corner of the bladder, and then runs medially within the posterior bladder wall before opening into the bladder’s interior. This oblique entry into the bladder prevents backflow of urine from the bladder into the ureters, because any increase of pressure within the bladder compresses the bladder wall, thereby closing the distal ends of the ureters.

The histological structure of the tubular ureters is the same as that of the renal calices and renal pelvis; the walls have three basic layers: a mucosa, a muscularis, and an adventitia.

  • The lining mucosa is composed of a transitional epithelium that stretches when the ureters fill with urine (see Figure 3) and a lamina propria composed of a stretchy, fibroelastic connective tissue containing rare patches of lymphoid tissue.
  • The middle muscularis consists of two layers: an inner longitudinal layer and an outer circular layer of smooth muscle. A third layer of muscularis, an external longitudinal layer, appears in the inferior third of the ureter.
  • The external adventitia of the ureter wall is a typical connective tissue.

Ureter function

The ureters play an active role in transporting urine. Distension of the ureter by entering urine stimulates its muscularis to contract, setting up peristaltic waves that propel urine to the bladder. This means that urine does not reach the bladder by gravity alone. Although the ureters are innervated by both sympathetic and parasympathetic nerve fibers, neural control of their peristalsis appears to be insignificant compared to the local stretch response of ureteric smooth muscle.

Figure 1. The Urinary Tract

urinary tract diagram

Figure 2. Normal Kidney Anatomy

kidney

Figure 3. Microscopic structure of the ureter

Microscopic structure of the ureter

Ureter pain

A kidney stone might cause severe pain by obstructing and distending a ureter. Ureter pain is a visceral pain, the pain is felt in or just deep to the skin that overlies the stimulated organ, or in a surface area far from the stimulated organ (see Figure 4). Figure 4 shows skin regions to which visceral pain may be referred. In general, the visceral organ involved and the area to which the pain is referred are served by the same segment of the spinal cord.

Kidney stones affect up to 5% of the population, with a lifetime risk of passing a kidney stone of about 8-10% 1. About 1/1000 adults in the US is hospitalized annually because of kidney stones, which are also found in about 1% of all autopsies 2. Up to 12% of men and 6% of women will develop a urinary calculus by age 70 2.

Kidney stones may remain within the kidney or renal collecting system or be passed into the ureter and bladder. During passage, the stones may irritate the ureter and may become lodged, obstructing urine flow and causing hydroureter and sometimes hydronephrosis. Common areas of lodgment include the following:

  • Ureteropelvic junction
  • Distal ureter (at the level of the iliac vessels)
  • Ureterovesical junction

Larger kidney stones are more likely to become lodged. Typically, a kidney stone must have a diameter > 5 mm to become lodged.

Kidney stones ≤ 5 mm are likely to pass spontaneously.

Even partial obstruction causes decreased glomerular filtration, which may persist briefly after the calculus has passed. With hydronephrosis and elevated glomerular pressure, renal blood flow declines, further worsening renal function. Generally, however, in the absence of infection, permanent renal dysfunction occurs only after about 28 days of complete obstruction.

Secondary infection can occur with long-standing obstruction, but most patients with calcium-containing calculi do not have infected urine.

What are the complications of kidney stones ?

Complications of kidney stones are rare if you seek treatment from a health care professional before problems occur.

If kidney stones are not treated, they can cause:

  • hematuria, or blood in the urine
  • severe pain
  • urinary tract infections (UTIs), including kidney infections (pyelonephritis)
  • loss of kidney function

Figure 4. Ureter pain (referred pain)

ureter referred pain

What are Symptoms and Signs of Kidney Stone

Large kidney stones remaining in the kidney or renal collecting system are often asymptomatic unless they cause obstruction and/or infection 2. Severe pain, often accompanied by nausea and vomiting, usually occurs when kidney stones pass into the ureter and cause acute obstruction. Sometimes gross hematuria also occurs.

The person with kidney stone may be in obvious extreme discomfort, often ashen and diaphoretic (sweating heavily). The person with kidney stone with renal colic may be unable to lie still and may pace, writhe, or constantly shift position. The abdomen may be somewhat tender on the affected side as palpation increases pressure in the already-distended kidney (costovertebral angle tenderness), but peritoneal signs (guarding, rebound, rigidity) are lacking.

For some patients, the first symptom is hematuria or either gravel or a calculus in the urine. Other patients may have symptoms of a urinary tract infection, such as fever, dysuria (painful urination) or cloudy or foul-smelling urine.

Symptoms of kidney stones include:

  • sharp pains in your back, side, lower abdomen, or groin
  • pink, red, or brown blood in your urine, also called hematuria
  • a constant need to urinate
  • pain while urinating
  • inability to urinate or can only urinate a small amount
  • cloudy or bad-smelling urine.

See a health care professional right away if you have any of these symptoms. These symptoms may mean you have a kidney stone or a more serious condition.

Your pain may last for a short or long time or may come and go in waves. Along with pain, you may have

  • nausea
  • vomiting

Other symptoms include:

  • fever
  • chills

Ectopic ureter

An ectopic ureter opens at a site other than the posteriolateral aspect of trigone and it also may open outside the urinary system 3. Ectopia is usually associated with duplex kidney and in general, 80% of ectopic ureters arise from the upper pole of a completely duplicated system 4, 5. If an ectopic ureter drains a single kidney, it is called a single system ectopic ureter 6. Single system ectopic ureters are rarely occurring only in 20% of the ureteric ectopia 7. In general, 80% of ectopic ureters arise from the upper pole of a completely duplicated system. Ectopic ureters draining single systems are rare 8 occurring only in 20% cases 9.

Ectopic ureters are common in females, 80% of which are duplicated and present at birth or in childhood 10. The urethra and vaginal vestibule are the most common sites of drainage in females. Bilateral single-system ectopic ureters are the rarest variety of ureteral ectopia.

The cause of ectopic ureter is unknown. The ureters are derived from the mesonephric duct outpouching known as the ureteric bud. The ureters find their way into the definitive bladder as the distal mesonephric duct is absorbed into the developing bladder to form the trigone, bladder neck, and proximal urethra. Ectopic ureters draining into the female genital tract are thought to be via embryonic remnants of the mesonephric duct (Gartner’s duct), which breaks open into the Mullerian system. This elusive embryonic event is unexplained and rare, more so in bilateral, single ectopic ureters. Occurrence of a simultaneous urogenital abnormality is expected here, such as agenesis of urinary bladder or persistent urogenital sinus. As for the etiology of renal dysplasia is not yet quite clear either. It has been postulated that failure of vascular supply during embryologic development prevents the kidney from developing normally and causes formation of a small primary organ that contains embryonal tissues. Some researchers believe that it is the obstruction of the ureter during an early phase of the embryo that stops development of the kidney 11.

Bilateral ectopic ureters in females usually present early with constant dribbling of urine. An ectopic ureter that inserts either into the urethra distal to the sphincter or into the vagina in a girl typically presents with continuous wetting despite an otherwise normal micturition pattern. Other possible signs and symptoms are urinary tract infection, abdominal pain, and renal failure.

The diagnostic work-up included ultrasonography, intravenous pyelography (IVP), micturating cystourethrogram (MCU), magnetic resonance urogram and computed tomography (CT scan). Computed tomography (CT scan) was crucial for arriving at a diagnosis, although magnetic resonance urogram can more precise 12. Patients usually underwent examination under anesthesia (EUA) and cystourethrovaginoscopy immediately before the operation.

The issue of continence is discussed by Podesta et al. 13 in their article, in which they inferred that the bladder in bilateral, single ectopic ureters may retain a good continence mechanism with adequate augmentation.

Treatment can be in form of ureteral reimplantation when relative renal function is 10% or more 14 or nephroureterectomy when relative renal function is less than 10% 15. In patients with bilateral anomalies or marginal renal function, reimplantation is of choice for salvaging renal mass 16.

The surgical treatment included nephroureterectomy for non-functioning kidney, heminephroureterectomy for non functioning upper pole of duplex kidney with ectopic ureters, ureteric reimplantation and ureteropyelostomy 17. In the follow-up period ranging from 1 to 5 years, 75% of patients achieved continence; however, 22% of cases with bilateral single-system ectopic ureter and 4% case of unilateral single-system ectopic ureter, who also had a patulous bladder neck, continued to dribble urine. Single-system ectopic ureter was more common than duplex with ectopic ureter. A large number of functioning renal units associated with single-system ectopic ureter deserved preservation. The success of surgical treatment in terms of achievement of continence was high and depended on the integrity of the bladder neck 17.

Before ureteronephrectomy, it is better to fill the bladder with methylene blue saline either via a thin needle or perurethrally and observe whether blue liquid comes from the perineum so as to confirm the diagnosis. Because the dysplastic kidney is usually located abnormally in the retroperitoneum below the normal kidney location, care is needed not to misdiagnose it as a solitary kidney by exploring only the normal kidney location near the lumbar vertebrae. [23],[24] Its merits include minor trauma, less time spent, rapid recovery, short hospitalization and low cost and it may be especially suitable when the precise location of the dysplastic kidney cannot be predicted preoperatively.

Ureter cancer

Primary transitional cell carcinoma of the ureter is one of the main types of primary upper tract urothelial carcinomas, which are rare and heterogeneous diseases that account for approximately 5% of all urothelial tumors 18. Since 2004, the estimated annual incidence of transitional cell carcinoma of the ureter is only 1.8 cases per 100,000 person-years in the United States, according to the rate session in the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program statistic 19. More men (2.7/100,000) than women (1.1/100.000) are likely to be affected. Primary transitional cell carcinoma of the ureter is an aggressive disease with a high progression rate, as over half of cases are invasive and approximately one-quarter of them have a regional metastasis at diagnosis compared to 15% and 20% for all bladder tumors 20. Most patients with this disease have a single ureter affected, and the disease affects both ureters in only 2–4% of patients 21.

Because of its biologic heterogeneity, prognosis and different treatment options, primary transitional cell carcinoma of the ureter makes treatment decisions difficult. Recommendations for the evaluation and treatment of primary transitional cell carcinoma of the ureter are mainly based on extrapolations of conclusions from high-evidence-level trials performed in patients with urothelial carcinoma of the urinary bladder. The cancer-directed surgical procedure is considered to be the gold standard of treatment 22. Adjuvant radiation and chemotherapy should also be considered in patients with high-risk disease, while patients with low-risk disease may benefit from a more conservative approach, according to the National Comprehensive Cancer Network guidelines 23.

The median overall survival for ureter cancer was 46 months, and the 5-year overall survival rate was 41.8%. The median cause-specific survival (a net survival measure representing cancer survival in the absence of other causes of death) was 78 months, and the 5-year cause-specific survival rate was 54.3%. Multivariate analysis identified tumor grade, tumor size, American Joint Committee on Cancer TNM stage, M stage, cancer-directed surgical procedure and radiation as independent factors of primary transitional cell carcinoma of the ureter. For early stage patients, the surgical procedure was associated with fairly longer survival and additional radiation may cause more harm than benefit. Meanwhile, for advanced stage patients, the impact of surgery on overall survival and cause-specific survival greatly decreased. Radiation exerted a very limited impact on clinical outcomes. Patients with bad tumor differentiation or a large tumor size were more likely to have advanced stage disease.

Studies of adjuvant chemotherapy for ureter cancer have had negative results, such as those on radiation 24. Studies have found no significant difference in the survival of patients, regardless of the administration of adjuvant chemotherapy 25. Traditional chemotherapeutic regimens, such as methotrexate, vinblastine, doxorubicin, cisplatin or gemcitabine and cisplatin, cannot offer as strong of a support. Cohen 26 indicated that a few patients underwent neoadjuvant chemotherapy, which is defined as surgery within 180 days after the first chemotherapy claim. Neoadjuvant chemotherapy patients showed a better cause-specific survival than surgery only patients, while the differences did not reach statistical significance because of the relatively small sample size. Likewise, with few patients undergoing neoadjuvant therapy, there was no demonstrable survival advantage for this approach. Hence, targeted therapies based on molecular alterations require further investigation.

The rest of the discussion on ureter cancer will be based on bladder cancer because primary transitional cell carcinoma of the ureter is rare, few studies focusing on this disease have been reported.

Risk of bladder cancer

Bladder cancer occurs mainly in older people. About 9 out of 10 people with this cancer are over the age of 55. The average age at the time of diagnosis is 73.

Men are about 3 to 4 times more likely to get bladder cancer during their lifetime than women. Overall, the chance men will develop this cancer during their life is about 1 in 26. For women, the chance is about 1 in 88. But each person’s chances of getting bladder cancer can be affected by certain risk factors.

Whites are diagnosed with bladder cancer about twice as often as African Americans or Hispanic Americans.

Bladder Cancer Risk Factors

A risk factor is anything that changes your chance of getting a disease such as cancer. Different cancers have different risk factors. Some risk factors, like smoking, can be changed. Others, like a person’s age or family history, can’t be changed.

But having a risk factor, or even several, does not mean that you will get the disease. Many people with risk factors never get bladder cancer, while others with this disease may have few or no known risk factors.

Still, it’s important to know about the risk factors for bladder cancer because there may be things you can do that might lower your risk of getting it. If you are at higher risk because of certain factors, you might be helped by tests that could find it early, when treatment is most likely to be effective.

Several risk factors make a person more likely to develop bladder cancer.

Risk factors you can change

Smoking

Smoking is the most important risk factor for bladder cancer. Smokers are at least 3 times as likely to get bladder cancer as nonsmokers. Smoking causes about half of all bladder cancers in both men and women.

Workplace exposures

Certain industrial chemicals have been linked with bladder cancer. Chemicals called aromatic amines, such as benzidine and beta-naphthylamine, which are sometimes used in the dye industry, can cause bladder cancer.

Workers in other industries that use certain organic chemicals also may have a higher risk of bladder cancer. Industries carrying higher risks include makers of rubber, leather, textiles, and paint products as well as printing companies. Other workers with an increased risk of developing bladder cancer include painters, machinists, printers, hairdressers (probably because of heavy exposure to hair dyes), and truck drivers (likely because of exposure to diesel fumes).

Cigarette smoking and workplace exposures can act together to cause bladder cancer. Smokers who also work with cancer-causing chemicals have an especially high risk of bladder cancer.

Certain medicines or herbal supplements

According to the US Food and Drug Administration (FDA), use of the diabetes medicine pioglitazone (Actos) for more than one year may be linked with an increased risk of bladder cancer. This possible link is still an area of active research.

Dietary supplements containing aristolochic acid (mainly in herbs from the Aristolochia family) have been linked with an increased risk of urothelial cancers, including bladder cancer.

Arsenic in drinking water

Arsenic in drinking water has been linked with a higher risk of bladder cancer in some parts of the world. The chance of being exposed to arsenic depends on where you live and whether you get your water from a well or from a public water system that meets the standards for low arsenic content. For most Americans, drinking water is not a major source of arsenic.

Not drinking enough fluids

People who drink a lot of fluids, especially water, each day tend to have lower rates of bladder cancer. This might be because they empty their bladders more often, which could keep chemicals from lingering in their bladder.

Risk factors you cannot change

Race and ethnicity

Whites are about twice as likely to develop bladder cancer as African Americans and Hispanics. Asian Americans and American Indians have slightly lower rates of bladder cancer. The reasons for these differences are not well understood.

Age

The risk of bladder cancer increases with age. About 9 out of 10 people with bladder cancer are older than 55.

Gender

Bladder cancer is much more common in men than in women.

Chronic bladder irritation and infections

Urinary infections, kidney and bladder stones, bladder catheters left in place a long time, and other causes of chronic bladder irritation have been linked with bladder cancer (especially squamous cell carcinoma of the bladder), but it’s not clear if they actually cause bladder cancer.

Schistosomiasis (also known as bilharziasis), an infection with a parasitic worm that can get into the bladder, is also a risk factor for bladder cancer. In countries where this parasite is common (mainly in Africa and the Middle East), squamous cell cancers of the bladder are seen much more often. This is an extremely rare cause of bladder cancer in the United States.

Personal history of bladder or other urothelial cancer

Urothelial carcinomas can sometimes form in different areas in the bladder, as well as in the lining of the kidney, the ureters, and urethra. Having a cancer in the lining of any part of the urinary tract puts you at higher risk of having another cancer, either in the same area as before, or in another part of the urinary tract. This is true even when the first tumor is removed completely. For this reason, people who have had bladder cancer need careful follow-up to look for new cancers.

Bladder birth defects

Before birth, there is a connection between the belly button and the bladder. This is called the urachus. If part of this connection remains after birth, it could become cancerous. Cancers that start in the urachus are usually adenocarcinomas, which are made up of cancerous gland cells. About one-third of the adenocarcinomas of the bladder start here. However, this is still rare, accounting for less than half of 1% of all bladder cancers.

Another rare birth defect called exstrophy greatly increases a person’s risk of bladder cancer. In bladder exstrophy, both the bladder and the abdominal wall in front of the bladder don’t close completely during fetal development and are fused together. This leaves the inner lining of the bladder exposed outside the body. Surgery soon after birth can close the bladder and abdominal wall (and repair other related defects), but people who have this still have a higher risk for urinary infections and bladder cancer.

Genetics and family history

People who have family members with bladder cancer have a higher risk of getting it themselves. Sometimes this may be because the family members are exposed to the same cancer-causing chemicals (such as those in tobacco smoke). They may also share changes in some genes (like GST and NAT) that make it hard for their bodies to break down certain toxins, which can make them more likely to get bladder cancer.

A small number of people inherit a gene syndrome that increases their risk for bladder cancer. For example:

  • A mutation of the retinoblastoma (RB1) gene can cause cancer of the eye in infants, and also increases the risk of bladder cancer.
  • Cowden disease, caused by mutations in the PTEN gene, is linked mainly to cancers of the breast and thyroid. People with this disease also have a higher risk of bladder cancer.
  • Lynch syndrome (also known as hereditary non-polyposis colorectal cancer, or HNPCC) is linked mainly to colon and endometrial cancer. People with this syndrome might also have an increased risk of bladder cancer (as well as other cancers of the urinary tract).

Prior chemotherapy or radiation therapy

Taking the chemotherapy drug cyclophosphamide (Cytoxan) for a long time can irritate the bladder and increase the risk of bladder cancer. People taking this drug are often told to drink plenty of fluids to help protect the bladder from irritation.

People who are treated with radiation to the pelvis are more likely to develop bladder cancer.

What Causes Bladder Cancer ?

Researchers do not know exactly what causes most bladder cancers. But they have found some risk factors (see What are the risk factors for bladder cancer?) and are starting to understand how they cause cells in the bladder to become cancer.

Certain changes in the DNA inside normal bladder cells can make them grow abnormally and form cancers. DNA is the chemical in each of our cells that makes up our genes, which control how our cells function. We usually look like our parents because they are the source of our DNA, but DNA affects more than just how we look.

Some genes control when cells grow, divide into new cells, and die:

  • Genes that help cells grow, divide, and stay alive are called oncogenes.
  • Genes that normally help control cell division, repair mistakes in DNA, or cause cells to die at the right time are called tumor suppressor genes.

Cancers can be caused by DNA changes (gene mutations) that turn on oncogenes or turn off tumor suppressor genes. Several different gene changes are usually needed for a cell to become cancer.

Acquired gene mutations

Most gene mutations related to bladder cancer develop during a person’s life rather than having been inherited before birth. Some of these acquired gene mutations result from exposure to cancer-causing chemicals or radiation. For example, chemicals in tobacco smoke can be absorbed into the blood, filtered by the kidneys, and end up in urine, where they can affect bladder cells. Other chemicals may reach the bladder the same way. But sometimes, gene changes may just be random events that sometimes happen inside a cell, without having an outside cause.

The gene changes that lead to bladder cancer are not the same in all people. Acquired changes in certain genes, such as the TP53 or RB1 tumor suppressor genes and the FGFR and RAS oncogenes, are thought to be important in the development of some bladder cancers. Changes in these and similar genes may also make some bladder cancers more likely to grow and invade the bladder wall than others. Research in this field is aimed at developing tests that can find bladder cancers at an early stage by finding their DNA changes.

Inherited gene mutations

Some people inherit gene changes from their parents that increase their risk of bladder cancer. But bladder cancer does not often run in families, and inherited gene mutations are not thought to be a major cause of this disease.

Some people seem to inherit a reduced ability to detoxify (break down) and get rid of certain types of cancer-causing chemicals. These people are more sensitive to the cancer-causing effects of tobacco smoke and certain industrial chemicals. Researchers have developed tests to identify such people, but these tests are not routinely done. It’s not certain how helpful the results of such tests might be, since doctors already recommend that all people avoid tobacco smoke and hazardous industrial chemicals.

Bladder Cancer Be Prevention

There is no sure way to prevent bladder cancer. Some risk factors such as age, gender, race, and family history can’t be controlled. But there may be things you can do that could lower your risk.

Don’t smoke

Smoking is thought to cause about half of all bladder cancers.

Limit exposure to certain chemicals in the workplace

Workers in industries that use certain organic chemicals may have a higher risk of bladder cancer. Workplaces where these chemicals are commonly used include the rubber, leather, printing materials, textiles, and paint industries. If you work in a place where you might be exposed to such chemicals, be sure to follow good work safety practices.

Some chemicals found in certain hair dyes might also increase risk, so it’s important for hairdressers and barbers who are exposed to these products regularly to use them safely. Most studies have not found that personal use of hair dyes increases bladder cancer risk.

Some research has suggested that people exposed to diesel fumes in the workplace might also have a higher risk of bladder cancer (as well as some other cancers), so limiting this exposure might be helpful.

Drink plenty of liquids

There is some evidence that drinking a lot of fluids – mainly water – might lower a person’s risk of bladder cancer.

Eat lots of fruits and vegetables

Some studies have suggested that a diet high in fruits and vegetables might help protect against bladder cancer, but other studies have not found this. Still, eating a healthy diet has been shown to have many benefits, including lowering the risk of some other types of cancer.

Can Bladder Cancer Be Found Early ?

Bladder cancer can sometimes be found early. Finding it early improves your chances that it can be treated successfully.

Screening for bladder cancer

Screening is the use of tests or exams to look for a disease in people who have no symptoms. At this time, no major professional organizations recommend routine screening of the general public for bladder cancer. This is because no screening test has been shown to lower the risk of dying from bladder cancer in people who are at average risk.

Some doctors may recommend bladder cancer tests for people at very high risk, such as:

  • People who had bladder cancer before
  • People who had certain birth defects of the bladder
  • People exposed to certain chemicals at work

Tests that might be used to look for bladder cancer

Tests for bladder cancer look for different substances or cancer cells in the urine.

Urinalysis: One way to test for bladder cancer is to check for blood in the urine (called hematuria). This can be done during a urinalysis, which is a simple test to check for blood and other substances in a sample of urine. This test is sometimes done during a general health checkup.

Blood in the urine is usually caused by benign (non-cancerous) conditions such as infections, but it also can be the first sign of bladder cancer. Large amounts of blood in urine can be seen if the urine turns pink or red, but a urinalysis is needed to find small amounts.

Urinalysis can help find some bladder cancers early, but it has not been shown to be useful as a routine screening test.

Urine cytology: In this test, the doctor uses a microscope to look for cancer cells in urine. Urine cytology does find some cancers, but it is not reliable enough to make a good screening test.

Urine tests for tumor markers: Several newer tests look for substances in the urine that might indicate bladder cancer. These include:

  • UroVysion™: This test looks for chromosome changes that are often seen in bladder cancer cells.
  • BTA tests: These tests look for a substance called bladder tumor-associated antigen (BTA), also known as CFHrp, in the urine.
  • Immunocyt™: This test looks at cells in the urine for the presence of substances such as mucin and carcinoembryonic antigen (CEA), which are often found on cancer cells.
  • NMP22 BladderChek®: This test looks for a protein called NMP22 in the urine, which is often found at higher levels in people who have bladder cancer.

These tests might find some bladder cancers early, but they can miss some as well. In other cases, the test result might be abnormal even in some people who do not have cancer. At this time the tests are used mainly to look for bladder cancer in people who already have signs or symptoms of cancer, or in people who have had a bladder cancer removed to check for cancer recurrence. Further research is needed before these or other newer tests are proven useful as screening tests.

Watching for possible symptoms of bladder cancer

While no screening tests are recommended for people at average risk, bladder cancer can often be found early because it causes blood in the urine or other urinary symptoms (see Signs and symptoms of bladder cancer). Many of these symptoms often have less serious causes, but it’s important to have them checked by a doctor right away so the cause can be found and treated, if needed. If the symptoms are from bladder cancer, finding it early offers the best chance for successful treatment.

Signs and Symptoms of Bladder Cancer

Bladder cancer can often be found early because it causes blood in the urine or other urinary symptoms.

Blood in the urine

In most cases, blood in the urine (called hematuria) is the first sign of bladder cancer. Sometimes, there is enough blood to change the color of the urine to orange, pink, or, less often, darker red. Sometimes, the color of the urine is normal but small amounts of blood are found when a urine test (urinalysis) is done because of other symptoms or as part of a general medical checkup.

Blood may be present one day and absent the next, with the urine remaining clear for weeks or months. If a person has bladder cancer, blood eventually reappears.

Usually, the early stages of bladder cancer cause bleeding but little or no pain or other symptoms.

Blood in the urine does not always mean you have bladder cancer. More often it is caused by other things like an infection, benign (non-cancerous) tumors, stones in the kidney or bladder, or other benign kidney diseases. But it’s important to have it checked by a doctor so the cause can be found.

Changes in bladder habits or symptoms of irritation

Bladder cancer can sometimes cause changes in urination, such as:

  • Having to urinate more often than usual
  • Pain or burning during urination
  • Feeling as if you need to go right away, even when the bladder is not full
  • Having trouble urinating or having a weak urine stream

These symptoms are also more likely to be caused by a urinary tract infection (UTI), bladder stones, an overactive bladder, or an enlarged prostate (in men). Still, it’s important to have them checked by a doctor so that the cause can be found and treated, if needed.

Symptoms of advanced bladder cancer

Bladder cancers that have grown large enough or have spread to other parts of the body can sometimes cause other symptoms, such as:

  • Being unable to urinate
  • Lower back pain on one side
  • Loss of appetite and weight loss
  • Feeling tired or weak
  • Swelling in the feet
  • Bone pain

Again, many of these symptoms are more likely to be caused by something other than bladder cancer, but it’s important to have them checked so that the cause can be found and treated, if needed.

If there is a reason to suspect you might have bladder cancer, the doctor will use one or more exams or tests to find out if it is cancer or something else.

How is bladder cancer diagnosed ?

Bladder cancer is often found because of signs or symptoms a person is having, or it might be found because of lab tests a person gets for another reason. If bladder cancer is suspected, exams and tests will be needed to confirm the diagnosis. If cancer is found, further tests will be done to help determine the extent ( stage) of the cancer.

Medical history and physical exam

Your doctor will want to get your medical history to learn more about your symptoms. The doctor might also ask about possible risk factors, including your family history.

A physical exam can provide other information about possible signs of bladder cancer and other health problems. The doctor might do a digital rectal exam, during which a gloved, lubricated finger is put into your rectum. If you are a woman, the doctor might do a pelvic exam as well. During these exams, the doctor can sometimes feel a bladder tumor, determine its size, and feel if and how far it has spread.

If the results of the exam are abnormal, your doctor will probably do lab tests and might refer you to a urologist (a doctor specializing in diseases of the urinary system and male reproductive system) for further tests and treatment.

Urine lab tests

Urinalysis

This is a simple test to check for blood and other substances in a sample of urine.

Urine cytology

For this test, a sample of urine is looked at with a microscope to see if it has any cancer or pre-cancer cells. Cytology is also done on any bladder washings taken during a cystoscopy. Cytology can help find some cancers, but this test is not perfect. Not finding cancer on this test doesn’t always mean you are cancer free.

Urine culture

If you are having urinary symptoms, this test may be done to see if an infection (rather than cancer) is the cause. Urinary tract infections and bladder cancers can have similar symptoms. For a urine culture, a sample of urine is put into a dish in the lab to allow any bacteria that are present to grow. It can take time for the bacteria to grow, so it may take a few days to get the results of this test.

Urine tumor marker tests

Different urine tests look for specific substances released by bladder cancer cells. One or more of these tests may be used along with urine cytology to help determine if you have bladder cancer. These include the tests for NMP22 (BladderChek) and BTA (BTA stat), the Immunocyt test, and the UroVysion test.

Some doctors find these urine tests useful in looking for bladder cancers, but they may not help in all cases. Most doctors feel that cystoscopy is still the best way to find bladder cancer. Some of these tests are more helpful when looking for a possible recurrence of bladder cancer in someone who has already had it, rather than finding it in the first place.

Cystoscopy

If bladder cancer is suspected, doctors will recommend a cystoscopy. For this exam, a urologist places a cystoscope – a thin tube with a light and a lens or a small video camera on the end – through the opening of the urethra and advances it into the bladder. Sterile salt water is then injected through the scope to expand the bladder and allow the doctor to look at its inner lining.

Cystoscopy can be done in a doctor’s office or in an operating room. Usually the first cystoscopy will be done in the doctor’s office using a small, flexible fiber-optic device. Some sort of local anesthesia may be used to numb the urethra and bladder for the procedure. If the cystoscopy is done using general anesthesia (where you are asleep) or spinal anesthesia (where the lower part of your body is numbed), the procedure is done in the operating room.

Fluorescence cystoscopy (also known as blue light cystoscopy) may be done along with routine cystoscopy. For this exam, a light-activated drug is put into the bladder during cystoscopy. It is taken up by cancer cells. When the doctor then shines a blue light through the cystoscope, any cells containing the drug will glow (fluoresce). This can help the doctor see abnormal areas that might have been missed by the white light normally used.

Transurethral resection of bladder tumor

If an abnormal area (or areas) is seen during a cystoscopy, it will be biopsied to see if it is cancer. A biopsy is the removal of small samples of body tissue to see if it is cancer. If bladder cancer is suspected, a biopsy is needed to confirm the diagnosis.

The procedure used to biopsy an abnormal area is a transurethral resection of bladder tumor (TURBT), also known as just a transurethral resection (TUR). During this procedure, the doctor removes the tumor and some of the bladder muscle near the tumor. The removed samples are then sent to a lab to look for cancer. If cancer is found, this can also show if it has invaded into the muscle layer of the bladder wall.

Bladder cancer can sometimes develop in more than one area of the bladder (or in other parts of the urinary tract). Because of this, the doctor may take samples from several different areas of the bladder, especially if cancer is strongly suspected but no tumor can be seen. Salt water washings of the inside the bladder may also be collected to look for cancer cells.

Biopsy results

The biopsy samples are sent to a lab, where they are looked at by a pathologist, a doctor who specializes in diagnosing diseases with lab tests. If bladder cancer is found, two important features are its invasiveness and grade.

Invasiveness: The biopsy can show how deeply the cancer has invaded (grown into) the bladder wall which is very important in deciding treatment.

  • If the cancer stays in the inner layer of cells without growing into the deeper layers, it is called non-invasive.
  • If the cancer grows into the deeper layers of the bladder, it is called invasive.

Invasive cancers are more likely to spread and are harder to treat.

You may also see a bladder cancer described as superficial or non-muscle invasive. These terms include both non-invasive tumors as well as any invasive tumors that have not grown into the main muscle layer of the bladder.

Grade: Bladder cancers are also assigned a grade, based on how they look under the microscope.

  • Low-grade cancers look more like normal bladder tissue. They are also called well-differentiated cancers. Patients with these cancers usually have a good prognosis (outlook).
  • High-grade cancers look less like normal tissue. These cancers may also be called poorly differentiated or undifferentiated. High-grade cancers are more likely to grow into the bladder wall and to spread outside the bladder. These cancers can be harder to treat.

Imaging tests

Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body.

If you have bladder cancer, your doctor may order some of these tests to see if the cancer has spread to structures near the bladder, to nearby lymph nodes, or to distant organs. If an imaging test shows enlarged lymph nodes or other possible signs of cancer spread, some type of biopsy might be needed to confirm the findings.

Intravenous pyelogram (IVP)

An intravenous pyelogram (IVP), also called an intravenous urogram (IVU), is an x-ray of the urinary system taken after injecting a special dye into a vein. This dye is removed from the bloodstream by the kidneys and then passes into the ureters and bladder. The dye outlines these organs on x-rays and helps show urinary tract tumors.

It’s important to tell your doctor if you have any allergies or have ever had a reaction to x-ray dyes, or if you have any type of kidney problems. If so, your doctor might choose to do another test instead.

Retrograde pyelogram

For this test, a catheter (thin tube) is placed through the urethra and up into the bladder or into a ureter. Then a dye is injected through the catheter to make the lining of the bladder, ureters, and kidneys easier to see on x-rays.

This test isn’t used as often as IVP, but it may be done (along with ultrasound of the kidneys) to look for tumors in the urinary tract in people who can’t have an IVP.

Computed tomography (CT) scan

A CT scan uses x-rays to make detailed cross-sectional images of your body. A CT scan of the kidney, ureters, and bladder is known as a CT urogram. It can provide detailed information about the size, shape, and position of any tumors in the urinary tract, including the bladder. It can also help show enlarged lymph nodes that might contain cancer, as well as other organs in the abdomen and pelvis.

CT-guided needle biopsy: CT scans can also be used to guide a biopsy needle into a suspected tumor. This is not used to biopsy tumors in the bladder, but it can be used to take samples from areas where the cancer may have spread. For this procedure, you lie on the CT scanning table while the doctor advances a biopsy needle through the skin and into the tumor.

Magnetic resonance imaging (MRI) scan

Like CT scans , MRI scans show detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays.

MRI images are particularly useful in showing if the cancer has spread outside of the bladder into nearby tissues or lymph nodes. A special MRI of the kidneys, ureters, and bladder, known as an MRI urogram, can be used instead of an IVP to look at the upper part of the urinary system.

Ultrasound

Ultrasound uses sound waves to create pictures of internal organs. It can be useful in determining the size of a bladder cancer and whether it has spread beyond the bladder to nearby organs or tissues. It can also be used to look at the kidneys.

This is usually an easy test to have, and it uses no radiation.

Ultrasound-guided needle biopsy: Ultrasound can also be used to guide a biopsy needle into a suspected area of cancer spread in the abdomen or pelvis.

Chest x-ray

A chest x-ray may be done to see if the bladder cancer has spread to the lungs. This test is not needed if a CT scan of the chest has been done.

Bone scan

A bone scan can help look for cancer that has spread to bones. Doctors don’t usually order this test unless you have symptoms such as bone pain, or if blood tests show the cancer might have spread to your bones.

For this test, you get an injection of a small amount of low-level radioactive material, which settles in areas of damaged bone throughout the body. A special camera detects the radioactivity and creates a picture of your skeleton.

A bone scan may suggest cancer in the bone, but to be sure, other imaging tests such as plain x-rays, MRI scans, or even a bone biopsy might be needed.

Biopsies to look for cancer spread

If imaging tests suggest the cancer might have spread outside of the bladder, a biopsy might be needed to be sure.

In some cases, biopsy samples of suspicious areas are obtained during surgery to remove the bladder cancer.

Another way to get a biopsy sample is to use a thin, hollow needle to take a small piece of tissue from the abnormal area. This is known as a needle biopsy, and by using it the doctor can take samples without an operation. Needle biopsies are sometimes done using a CT scan or ultrasound to help guide the biopsy needle into the abnormal area.

Bladder Cancer Stages

What is the stage of a cancer ?

The stage of a bladder cancer describes how far it has spread. It’s one of the most important factors in choosing treatment options and predicting a person’s prognosis (outlook). If you have bladder cancer, ask your cancer care team to explain its stage. This can help you make informed choices about your treatment.

There are actually 2 types of stages for bladder cancer.

  1. The clinical stage is the doctor’s best estimate of the extent of the cancer, based on the results of physical exams, cystoscopy, biopsies, and any imaging tests that are done (such as CT scans). These exams and tests are described in Tests for bladder cancer.
  2. If surgery is done to treat the cancer, the pathologic stage can be determined using the same factors as the clinical stage, plus what is found during surgery.

The clinical stage is used to help plan treatment. Sometimes, though, the cancer has spread farther than the clinical stage estimates. Pathologic staging is likely to be more accurate, because it gives your doctor a firsthand impression of the extent of your cancer.

Understanding your bladder cancer stage

A staging system is a standard way for the cancer care team to describe how far a cancer has spread. The staging system most often used for bladder cancer is the American Joint Committee on Cancer TNM system, which is based on 3 key pieces of information:

  • T describes how far the main (primary) tumor has grown through the bladder wall and whether it has grown into nearby tissues.
  • N indicates any cancer spread to lymph nodes near the bladder. Lymph nodes are bean-sized collections of immune system cells, to which cancers often spread first.
  • M indicates whether or not the cancer has spread (metastasized) to distant sites, such as other organs or lymph nodes that are not near the bladder.

Numbers or letters appear after T, N, and M to provide more details about each of these factors. Higher numbers mean the cancer is more advanced.
T categories for bladder cancer

The T category describes how far the main tumor has grown into the wall of the bladder (or beyond).

The wall of the bladder has 4 main layers.

  • The innermost lining is called the urothelium or transitional epithelium.
  • Beneath the urothelium is a thin layer of connective tissue, blood vessels, and nerves.
  • Next is a thick layer of muscle.
  • Outside of this muscle, a layer of fatty connective tissue separates the bladder from other nearby organs.

Nearly all bladder cancers start in the urothelium. As the cancer grows into or through the other layers in the bladder, it becomes more advanced.

TX: Main tumor cannot be assessed due to lack of information

T0: No evidence of a primary tumor

Ta: Non-invasive papillary carcinoma

Tis: Non-invasive flat carcinoma (flat carcinoma in situ, or CIS)

T1: The tumor has grown from the layer of cells lining the bladder into the connective tissue below. It has not grown into the muscle layer of the bladder.

T2: The tumor has grown into the muscle layer.

T2a: The tumor has grown only into the inner half of the muscle layer.
T2b: The tumor has grown into the outer half of the muscle layer.

T3: The tumor has grown through the muscle layer of the bladder and into the fatty tissue layer that surrounds it.

T3a: The spread to fatty tissue can only be seen by using a microscope.
T3b: The spread to fatty tissue is large enough to be seen on imaging tests or to be seen or felt by the surgeon.

T4: The tumor has spread beyond the fatty tissue and into nearby organs or structures. It may be growing into any of the following: the stroma (main tissue) of the prostate, the seminal vesicles, uterus, vagina, pelvic wall, or abdominal wall.

T4a: The tumor has spread to the stroma of the prostate (in men), or to the uterus and/or vagina (in women).
T4b: The tumor has spread to the pelvic wall or the abdominal wall.

Bladder cancer can sometimes affect many areas of the bladder at the same time. If more than one tumor is found, the letter m is added to the appropriate T category.

N categories for bladder cancer

The N category describes spread only to the lymph nodes near the bladder (in the true pelvis) and those along the blood vessel called the common iliac artery. These lymph nodes are called regional lymph nodes. Any other lymph nodes are considered distant lymph nodes. Spread to distant nodes is considered metastasis (described in the M category). Surgery is usually needed to find cancer spread to lymph nodes, since it is not often seen on imaging tests.

NX: Regional lymph nodes cannot be assessed due to lack of information.

N0: There is no regional lymph node spread.

N1: The cancer has spread to a single lymph node in the true pelvis.

N2: The cancer has spread to 2 or more lymph nodes in the true pelvis.

N3: The cancer has spread to lymph nodes along the common iliac artery.

M categories for bladder cancer

M0: There are no signs of distant spread.

M1: The cancer has spread to distant parts of the body. (The most common sites are distant lymph nodes, the bones, the lungs, and the liver.)
Stages of bladder cancer

Once the T, N, and M categories have been determined, this information is combined to find the overall cancer stage. Bladder cancer stages are defined using 0 and the Roman numerals I to IV (1 to 4). Stage 0 is the earliest stage, while stage IV is the most advanced.

Stage 0a (Ta, N0, M0)

The cancer is a non-invasive papillary carcinoma (Ta). It has grown toward the hollow center of the bladder but has not grown into the connective tissue or muscle of the bladder wall. It has not spread to nearby lymph nodes (N0) or distant sites (M0).

Stage 0is (Tis, N0, M0)

The cancer is a flat, non-invasive carcinoma (Tis), also known as flat carcinoma in situ (CIS). The cancer is growing in the inner lining layer of the bladder only. It has not grown inward toward the hollow part of the bladder, nor has it invaded the connective tissue or muscle of the bladder wall. It has not spread to nearby lymph nodes (N0) or distant sites (M0).

Stage I (T1, N0, M0)

The cancer has grown into the layer of connective tissue under the lining layer of the bladder but has not reached the layer of muscle in the bladder wall (T1). The cancer has not spread to nearby lymph nodes (N0) or to distant sites (M0).

Stage II (T2a or T2b, N0, M0)

The cancer has grown into the thick muscle layer of the bladder wall, but it has not passed completely through the muscle to reach the layer of fatty tissue that surrounds the bladder (T2). The cancer has not spread to nearby lymph nodes (N0) or to distant sites (M0).

Stage III (T3a, T3b, or T4a, N0, M0)

The cancer has grown into the layer of fatty tissue that surrounds the bladder (T3a or T3b). It might have spread into the prostate, uterus, or vagina, but it is not growing into the pelvic or abdominal wall (T4a). The cancer has not spread to nearby lymph nodes (N0) or to distant sites (M0).

Stage IV

One of the following applies:

T4b, N0, M0: The cancer has grown through the bladder wall and into the pelvic or abdominal wall (T4b). The cancer has not spread to nearby lymph nodes (N0) or to distant sites (M0).

OR

Any T, N1 to N3, M0: The cancer has spread to nearby lymph nodes (N1-N3) but not to distant sites (M0).

OR

Any T, any N, M1: The cancer has spread to distant lymph nodes or to sites such as the bones, liver, or lungs (M1).

Survival Rates for Bladder Cancer

Survival rates tell you what portion of people with the same type and stage of cancer are still alive a certain amount of time (usually 5 years) after they were diagnosed. They can’t tell you how long you will live, but they may help give you a better understanding about how likely it is that your treatment will be successful. Some people will want to know the survival rates for their cancer, and some people won’t.

Cancer survival rates don’t tell the whole story

Survival rates are often based on previous outcomes of large numbers of people who had the disease, but they can’t predict what will happen in any particular person’s case. There are a number of limitations to remember:

  • The numbers below are among the most current available. But to get 5-year survival rates, doctors have to look at people who were treated at least 5 years ago. As treatments are improving over time, people who are now being diagnosed with bladder cancer may have a better outlook than these statistics show.
  • These statistics are based on the stage of the cancer when it was first diagnosed. They do not apply to cancers that later come back or spread, for example.
  • The outlook for people with bladder cancer varies by the stage (extent) of the cancer – in general, the survival rates are higher for people with earlier stage cancers. But many other factors can affect a person’s outlook, such as age and overall health, and how well the cancer responds to treatment. The outlook for each person is specific to their circumstances.

Your doctor can tell you how these numbers may apply to you, as he or she is familiar with your particular situation.

Survival rates for bladder cancer

According to the most recent data, when including all stages of bladder cancer:

  • The 5-year relative survival rate is about 77%
  • The 10-year relative survival rate is about 70%
  • The 15-year relative survival rate is about 65%

Keep in mind that just as 5-year survival rates are based on people diagnosed and first treated more than 5 years ago, 10-year survival rates are based on people diagnosed more than 10 years ago (and 15-year survival rates are based on people diagnosed at least 15 years ago).

Survival rates, by stage

The numbers below are based on thousands of people diagnosed with bladder cancer from 1988 to 2001. These numbers come from the National Cancer Institute’s SEER database.

  • The 5-year relative survival rate for people with stage 0 bladder cancer is about 98%.
  • The 5-year relative survival rate for people with stage I bladder cancer is about 88%.
  • For stage II bladder cancer, the 5-year relative survival rate is about 63%.
  • The 5-year relative survival rate for stage III bladder cancer is about 46%.
  • Bladder cancer that has spread to other parts of the body is often hard to treat. Stage IV bladder cancer has a relative 5-year survival rate of about 15%. Still, there are often treatment options available for people with this stage of cancer.

Remember, these survival rates are only estimates – they can’t predict what will happen to any individual person. We understand that these statistics can be confusing and may lead you to have more questions. Talk to your doctor to better understand your specific situation.

Bladder cancer treatment

Depending on the stage of the cancer and other factors, treatment options for people with bladder cancer can include:

  • Surgery
  • Intravesical therapy
  • Chemotherapy
  • Radiation therapy
  • Immunotherapy

Sometimes, the best option might include more than one of type of treatment. Surgery, alone or with other treatments, is part of the treatment for most bladder cancers. Surgery can often remove early-stage bladder tumors. But a major concern in people with early-stage bladder cancer is that new cancers often form in other parts of the bladder over time. Removing the entire bladder (known as a radical cystectomy) is one way to avoid this, but it can have major side effects. If the entire bladder is not removed, other treatments may be given to try to reduce the risk of new cancers. Whether or not other treatments are given, close follow-up is needed to look for signs of new cancers in the bladder.

Which doctors treat bladder cancer ?

Depending on your options, you can have different types of doctors on your treatment team. The types of doctors who treat bladder cancers include:

  • Urologists: surgeons who specialize in treating diseases of the urinary system and male reproductive system
  • Radiation oncologists: doctors who treat cancer with radiation therapy
  • Medical oncologists: doctors who treat cancer with medicines such as chemotherapy and immunotherapy

You might have many other specialists on your treatment team as well, including physician assistants (PAs), nurse practitioners (NPs), nurses, psychologists, social workers, nutrition specialists, rehabilitation specialists, and other health professionals. See Health Professionals Associated With Cancer Care for more on this.

Making treatment decisions

It’s important to discuss all of your treatment options, including their goals and possible side effects, with your doctors to help make the decision that best fits your needs. Some important things to consider include:

  • Your age and expected life span
  • Any other serious health conditions you have
  • The stage and grade of your cancer
  • The likelihood that treatment will cure your cancer (or help in some other way)
  • Your feelings about the possible side effects from treatment

You may feel that you must make a decision quickly, but it’s important to give yourself time to absorb the information you have just learned. It’s also very important to ask questions if there is anything you’re not sure about.

Getting a second opinion

You may also want to get a second opinion. This can give you more information and help you feel more certain about the treatment plan you choose. If you aren’t sure where to go for a second opinion, ask your doctor for help.

Thinking about taking part in a clinical trial

Clinical trials are carefully controlled research studies that are done to get a closer look at promising new treatments or procedures. Clinical trials are one way to get state-of-the art cancer treatment. In some cases, they may be the only way to get access to newer treatments. They are also the best way for doctors to learn better methods to treat cancer. Still, they are not right for everyone.

If you would like to learn more about clinical trials that might be right for you, start by asking your doctor if your clinic or hospital conducts clinical trials.

Bladder Cancer Surgery

Surgery is part of the treatment for most bladder cancers. The type of surgery done depends on the stage (extent) of the cancer.

Transurethral resection of bladder tumor (TURBT)

A transurethral resection of bladder tumor (TURBT), also known as just a transurethral resection (TUR), is often used to determine if someone has bladder cancer and, if so, whether the cancer has invaded the muscle layer of the bladder wall.

This is also the most common treatment for early-stage or superficial (non-muscle invasive) bladder cancers. Most patients have superficial cancer when they are first diagnosed, so this is usually their first treatment. Some people might also get a second, more extensive TURBT as part of their treatment.

How Transurethral resection of bladder tumor (TURBT) is done

This surgery is done using an instrument put up the urethra, so it doesn’t require cutting into the abdomen. You will get either general anesthesia (where you are asleep) or regional anesthesia (where the lower part of your body is numbed).

For this operation, a type of rigid cystoscope called a resectoscope is placed into the bladder through the urethra. The resectoscope has a wire loop at its end to remove any abnormal tissues or tumors. The removed tissue is sent to a lab to be looked at by a pathologist.

After the tumor is removed, more steps may be taken to try to ensure that it has been destroyed completely. Any remaining cancer may be treated by fulguration (burning the base of the tumor) while looking at it with the cystoscope. Cancer can also be destroyed using a high-energy laser through the cystoscope.

Possible side effects

The side effects of TURBT are generally mild and do not usually last long. You might have some bleeding and pain when you urinate after surgery. You can usually return home the same day or the next day and can resume your usual activities within a week or two.

Even if the TURBT removes the tumor completely, bladder cancer often comes back (recurs) in other parts of the bladder. This might be treated with another TURBT. But if TURBT needs to be repeated many times, the bladder can become scarred and lose its capacity to hold much urine. Some people may have side effects such as frequent urination, or even incontinence (loss of control of urination).

In patients with a long history of recurrent, non-invasive low-grade tumors, the surgeon may sometimes just use fulguration to burn small tumors that are seen during cystoscopy (rather than removing them). This can often be done using local anesthesia (numbing medicine) in the doctor’s office. It is safe but can be mildly uncomfortable.

Cystectomy

When bladder cancer is invasive, all or part of the bladder may need to be removed. This operation is called a cystectomy.

Partial cystectomy: If the cancer has invaded the muscle layer of the bladder wall but is not very large and only in one place, it can sometimes be removed along with part of the bladder wall without taking out the whole bladder. The hole in the bladder wall is then closed. Nearby lymph nodes are also removed and examined for cancer spread. Only a small portion of people with cancer that has invaded the muscle can have this surgery.

The main advantage of this surgery is that the person keeps their bladder and doesn’t need reconstructive surgery (see below). But the remaining bladder may not hold as much urine, which means they will have to urinate more often. The main concern with this type of surgery is that bladder cancer can still recur in another part of the bladder wall.

Radical cystectomy: If the cancer is larger or is in more than one part of the bladder, a radical cystectomy will be needed. This operation removes the entire bladder and nearby lymph nodes. In men, the prostate and seminal vesicles are also removed. In women, the ovaries, fallopian tubes (tubes that connect the ovaries and uterus), the uterus (womb), cervix, and a small portion of the vagina are often removed along with the bladder.

General anesthesia (where you are in a deep sleep) is used for either type of cystectomy.

Typically, these procedures are done through a cut (incision) in the abdomen. You will need to stay in the hospital for about a week after the surgery. You can usually go back to your normal activities after several weeks.

In some cases, the surgeon may operate through several smaller incisions using special long, thin instruments, one of which has a tiny video camera on the end to see inside the pelvis. This is known as laparoscopic, or “keyhole” surgery. The surgeon may either hold the instruments directly or may sit at a control panel in the operating room and maneuver robotic arms to do the surgery (sometimes known as a robotic cystectomy). This type of surgery may result in less pain and quicker recovery because of the smaller incisions. But it hasn’t been around as long as the standard type of surgery, so it’s not yet clear if it is equally as effective.

It is important that any type of cystectomy be done by a surgeon with experience in treating bladder cancer. If the surgery is not done well, the cancer is more likely to come back.

Reconstructive surgery after radical cystectomy

If your whole bladder is removed, you will need another way to store urine and and remove it. Several types of reconstructive surgery can be done depending on your medical situation and personal preferences.

Incontinent diversion: One option may be to remove a short piece of your intestine and connect it to the ureters. This creates a passageway, known as an ileal conduit, for urine to pass from the kidneys to the outside of the body. Urine flows from the kidneys through the ureters into the ileal conduit. One end of the conduit is connected to the skin on the front of the abdomen by an opening called a stoma (also known as a urostomy).

After this procedure, a small bag is placed over the stoma to collect the urine, which comes out continuously in small amounts. The bag then needs to be emptied once it is full. This approach is sometimes called an incontinent diversion, because you no longer control the flow of urine out of the body.

Continent diversion: Another way for urine to drain is called a continent diversion. In this approach, a pouch is made from the piece of intestine that is attached to the ureters. One end of the pouch is connected to an opening (stoma) in the skin on the front of the abdomen. A valve is created in the pouch to allow urine to be stored there. You then empty the pouch several times a day by putting a drainage tube (catheter) into the stoma through the valve. Some people prefer this method because there is no bag on the outside.

Neobladder: A newer method routes the urine back into the urethra, restoring urination. To do this, the surgeon creates a neobladder – basically a new bladder made of a piece of intestine. As with the incontinent and continent diversions, the ureters are connected to the neobladder. The difference is that the neobladder is also sewn to the urethra. This lets the patient urinate normally. Over several months, most people regain the ability to urinate normally during the day, although many people might still have some incontinence at night.

If the cancer has spread or can’t be removed with surgery, a diversion may be made without removing the bladder. In this case, the purpose of the surgery is to prevent or relieve blockage of urine flow, rather than try to cure the cancer.

Risks and side effects of cystectomy

The risks with any type of cystectomy are much like those with any major surgery. Problems during or shortly after the operation can include:

  • Reactions to anesthesia
  • Bleeding from the surgery
  • Blood clots in the legs or lungs
  • Damage to nearby organs
  • Infections at the surgery site

Most people will have at least some pain after the operation, which is usually helped with pain medicines, if needed.

Effects on urination: Bladder surgery can affect how you urinate. If you have had a partial cystectomy, this might be limited to having to go more often (because your bladder can’t hold as much urine).

If you have a radical cystectomy, you will need reconstructive surgery (described above) to create a new way for urine to leave your body. Depending on the type of reconstruction, you might need to learn how to empty your urostomy bag or to put a catheter into your stoma. Aside from these changes, urinary diversion and urostomy can also lead to:

  • Infections
  • Urine leaks
  • Pouch stones
  • Blockage of urine flow

The physical changes that come from removing the bladder and having a urostomy can affect your quality of life as well. Discuss your feelings and concerns with your health care team.

Sexual effects of radical cystectomy in men: Radical cystectomy removes the prostate gland and seminal vesicles. Since these glands make most of the seminal fluid, removing them means that a man will no longer make semen. He can still have an orgasm, but it will be “dry.”

After surgery, many men have nerve damage that affects their ability to have erections. In some men this may improve over time. Generally, the younger a man is, the more likely he is to regain the ability to have full erections. If this issue is important to you, discuss it with your doctor before surgery. Newer surgical techniques may lower the chance of erection problems.

Sexual effects of radical cystectomy in women: This surgery often removes the front part of the vagina. This can make sex less comfortable for some women, although most of the time intercourse is still possible. One option is to have the vagina rebuilt, which is known as vaginal reconstruction. There is more than one way to do this, so talk with your surgeon about the pros and cons of each. Whether or not you have reconstruction, there are many ways to make sex more comfortable.

Radical cystectomy can also affect a woman’s ability to have an orgasm if the nerve bundles that run along each side of the vagina are damaged. Talk with your doctor about whether these nerves can be left in place during surgery.

If the surgeon takes out the end of the urethra where it opens outside the body, the clitoris can lose some of its blood supply, which might affect sexual arousal. Talk with your surgeon about whether the end of the urethra can be spared.

Sexual effects of urostomy: It’s normal for both men and women to be concerned about having a sex life with a urostomy. Having your ostomy pouch fit correctly and emptying it before sex reduces the chances of a major leak. A pouch cover or small ostomy pouch can be worn with a sash to keep the pouch out of the way. Wearing a snug fitting shirt may be even more comfortable. Choose sexual positions that keep your partner’s weight from rubbing against the pouch.

Intravesical Therapy for Bladder Cancer

With intravesical therapy, the doctor puts a liquid drug directly into the bladder (through a catheter) rather than giving it by mouth or injecting it into a vein. The drug can affect the cells lining the bladder without having major effects in other parts of the body

When might intravesical therapy be used ?

Intravesical therapy is used after transurethral resection of bladder tumor (TURBT) for non-invasive (stage 0) or minimally invasive (stage I) bladder cancers to help keep the cancer from coming back.

It is used only for these early-stage cancers because medicines given this way mainly affect the cells lining the inside of the bladder, with little to no effect on cells elsewhere. This means that any cancer cells outside of the bladder lining, including those that have grown deeply into the bladder wall, are not treated. Drugs put into the bladder also can’t reach cancer cells in the kidneys, ureters, and urethra, or those that have spread to other organs.

Types of intravesical therapy

There are two types of intravesical therapy:

  1. Immunotherapy
  2. Chemotherapy

Intravesical immunotherapy

Immunotherapy causes the body’s own immune system to attack the cancer cells.

Bacillus Calmette-Guerin therapy: Bacillus Calmette-Guerin (BCG) is the main intravesical immunotherapy for treating early-stage bladder cancer. BCG is a germ that is related to the one that causes tuberculosis (TB), but it doesn’t usually cause serious disease. BCG is put directly into the bladder through a catheter. The body’s immune system cells are attracted to the bladder and activated by BCG, which in turn affects the bladder cancer cells. Treatment is usually started a few weeks after a TURBT and is given once a week for 6 weeks. Sometimes long-term maintenance BCG therapy is given.

Treatment with BCG can cause symptoms that feel like having the flu, such as fever, chills, and fatigue. It can also cause a burning feeling in the bladder. Rarely, BCG can spread through the body, leading to a serious infection. One sign of this can be a high fever that isn’t helped by aspirin or similar medicines. If this happens, call your doctor right away.

Intravesical chemotherapy

For this treatment, chemotherapy (chemo) drugs are put directly into the bladder through a catheter. These drugs kill actively growing cancer cells. Many of these same drugs can also be given systemically (usually into a vein) to treat more advanced stages of bladder cancer.

Mitomycin is the drug used most often for intravesical chemotherapy. Other drugs that can be used include valrubicin, docetaxel, thiotepa, and gemcitabine. Delivery of mitomycin into the bladder along with heating the inside of the bladder, a treatment called electromotive mitomycin therapy, may work even better than giving intravesical mitomycin the usual way.

A major advantage of giving chemo directly into the bladder instead of injecting it into the bloodstream is that the drugs usually do not reach other parts of the body. This helps people avoid many of the side effects that can occur with chemo..

The main side effects of intravesical chemo are irritation and a burning feeling in the bladder.

Chemotherapy for Bladder Cancer

Chemotherapy (chemo) is the use of drugs to treat cancer. Chemo for bladder cancer can be given in 2 different ways:

  1. Intravesical chemotherapy: For this treatment, the chemo drug is put directly into the bladder. This type of chemo is used only for very early-stage bladder cancers. It is described in Intravesical therapy for bladder cancer.
  2. Systemic chemotherapy: When chemo drugs are given in pill form or injected into a vein (IV) or muscle (IM), the drugs enter the bloodstream and travel throughout the body. This is called systemic chemotherapy. Systemic chemo can affect cancer cells far away from the main tumor.

When might chemotherapy be used ?

Systemic chemo can be used :

  • Before surgery to try to shrink a large tumor so that it can be removed more easily and to lower the chance the cancer will come back. Giving chemo before surgery is known as neoadjuvant therapy.
  • After surgery (or sometimes after radiation therapy). This is called adjuvant therapy. The goal of adjuvant therapy is to kill any cancer cells that remain after other treatments but are too small to be seen. This can lower the chance that the cancer will come back later.
  • In people getting radiation therapy, to help the radiation work better.
  • As the main treatment for advanced bladder cancers, such as those that have spread to distant parts of the body.

Which chemo drugs are used to treat bladder cancer ?

Chemo drugs may be used alone or in combination, depending on what they’re being used for, a person’s overall health, and other factors.

When chemo is given with radiation, the most common drugs used include:

  • Cisplatin
  • Cisplatin plus fluorouracil (5-FU)
  • Mitomycin with 5-FU

When chemo is used without radiation, the most common combinations include:

  • Gemcitabine and cisplatin
  • Methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (called MVAC)
  • Cisplatin, methotrexate, and vinblastine (called CMV)
  • Carboplatin and either paclitaxel or docetaxel (for patients with poor kidney function)

For some people, the side effects of getting more than one chemo drug might be too much to handle. For those people, treatment with a single drug, such as gemcitabine or cisplatin, may be a good option. Other drugs sometimes used alone for bladder cancer include carboplatin, docetaxel, paclitaxel, doxorubicin, 5-FU, methotrexate, vinblastine, ifosfamide, and pemetrexed.

Doctors give chemo in cycles, with each period of treatment followed by a rest period to allow the body time to recover. Each cycle typically lasts for a few weeks.

Most bladder cancers are transitional cell (urothelial) cancers, but there are other types as well, including squamous cell carcinoma, adenocarcinoma, and small cell carcinoma. Chemo for these rare types of bladder cancer may use drugs different from those listed above.

Side effects of chemotherapy

Chemo drugs attack cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow (where new blood cells are made), the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemo, which can lead to side effects.

The side effects of chemo depend on the type and dose of drugs given and how long they are taken. When chemo and radiation are given at the same time, side effects tend to be worse. Common side effects of chemo include:

  • Nausea and vomiting
  • Loss of appetite
  • Hair loss
  • Mouth sores
  • Diarrhea or constipation
  • Increased risk of infections (because of a shortage of white blood cells)
  • Bleeding or bruising after minor cuts or injuries (due to a shortage of blood platelets)
  • Fatigue (because of a shortage of red blood cells)

These side effects usually go away after treatment is finished. There are often ways to lessen these side effects. For example, drugs can be given to help prevent or reduce nausea and vomiting. Ask your health care team about the side effects your chemo drugs may cause.

Some chemo drugs can cause other, less common side effects. For example, drugs such as cisplatin, carboplatin, docetaxel, and paclitaxel can damage nerves. This can sometimes lead to symptoms (mainly in the hands and feet) such as pain, burning or tingling sensations, sensitivity to cold or heat, or weakness. This is called peripheral neuropathy. Some chemo drugs have been linked to an increased risk of leukemia later in life, but this is very rare.

Be sure to report any side effects to your medical team so that they can be treated promptly. In some cases, the doses of the chemo drugs may need to be reduced or treatment may need to be delayed or stopped to prevent the effects from getting worse.

Radiation Therapy for Bladder Cancer

Radiation therapy uses high-energy radiation to kill cancer cells.

When might radiation therapy be used ?

Radiation therapy can be used:

  • As part of the treatment for some early stage bladder cancers, after surgery that doesn’t remove the whole bladder (such as TURBT)
  • As the main treatment for people with earlier-stage cancers who can’t have surgery
  • As part of the initial treatment for advanced bladder cancer
  • To help prevent or treat symptoms caused by advanced bladder cancer

Radiation therapy is often combined with chemotherapy to make the radiation more effective. This is known as chemoradiation.

How is radiation therapy given ?

The type of radiation most often used to treat bladder cancer, known as external beam radiation therapy, focuses radiation from a source outside of the body on the cancer.

Before your treatments start, your radiation team will take careful measurements to find the correct angles for aiming the radiation beams and the proper dose of radiation. This planning session, called simulation, usually includes getting imaging tests such as CT or MRI scans.

The treatment is much like getting an x-ray, but the radiation is stronger. The procedure itself is painless. Each treatment lasts only a few minutes, but the setup time – getting you into place for treatment – usually takes longer. Most often, radiation treatments are given 5 days a week for several weeks.

Possible side effects of radiation therapy

Side effects of radiation depend on the dose given and the area being treated. They can include:

  • Skin changes in areas getting radiation, ranging from redness to blistering and peeling
  • Nausea and vomiting
  • Bladder symptoms, like burning or pain when you urinate, feeling the need to go often, or blood in urine
  • Diarrhea
  • Fatigue
  • Low blood counts, which can lead to fatigue, easy bruising or bleeding, or increased risk of infection

These effects usually go away after treatment, although some people can have longer-term problems. For example:

In some people radiation treatments can lead to incontinence (problems holding urine) later on.
Radiation can damage the lining of the bladder. This is known as radiation cystitis and can cause long-term problems such as blood in the urine or painful urination.

If you have side effects from radiation therapy, discuss them with your health care team. They can suggest ways to ease many of them.

Immunotherapy for Bladder Cancer

Immunotherapy is the use of medicines to help a person’s own immune system recognize and destroy cancer cells. Immunotherapy can sometimes be used to treat bladder cancer.

Intravesical Bacillus Calmette-Guerin (BCG) (for some early-stage cancers)

Bacillus Calmette-Guerin (BCG) is a type of bacteria related to the one that causes tuberculosis. While it doesn’t usually cause a person to get sick, it can help trigger an immune response. Bacillus Calmette-Guerin (BCG) can be put directly into the bladder (as a liquid) through a catheter. This activates immune system cells in the bladder, which in turn can attack bladder cancer cells.

For some early-stage cancers, BCG can be used after transurethral resection of bladder tumor (TURBT) to help keep the cancer from coming back. For more details on this treatment, see the section on intravesical therapy.

Immune checkpoint inhibitors (for advanced cancers)

An important part of the immune system is its ability to keep itself from attacking normal cells in the body. To do this, it uses “checkpoints” – molecules on immune cells that need to be turned on (or off) to start an immune response. Cancer cells sometimes use these checkpoints to avoid being attacked by the immune system. But newer drugs that target these checkpoints hold a lot of promise as cancer treatments.

Atezolizumab (Tecentriq), durvalumab (Imfinzi), and avelumab (Bavencio) are drugs that target PD-L1, a protein on cells (including some cancer cells) that helps keep the immune system from attacking them. By blocking PD-L1, these drugs boost the immune response against the cancer cells. This can shrink some tumors or slow their growth.

Nivolumab (Opdivo) and pembrolizumab (Keytruda) target PD-1, another protein that normally helps keep the immune system in check. Blocking PD-1 can help the immune system attack the cancer cells.

Any of these drugs can be used in people with advanced bladder that starts growing again after chemotherapy. Atezolizumab and pembrolizumab can also be used in people who can’t get the chemo drug cisplatin for some reason.

These drugs are given as intravenous (IV) infusions, typically every 2 or 3 weeks.

Possible side effects

Common side effects of these drugs include fatigue, nausea, loss of appetite, fever, urinary tract infections, rash, diarrhea, and constipation.

Less often, more serious side effects can occur. These drugs work by basically removing the brakes on the body’s immune system. Sometimes the immune system starts attacking other parts of the body, which can cause serious or even life-threatening problems in the lungs, intestines, liver, hormone-making glands, or other organs.

It’s very important to report any new side effects to your health care team promptly. If serious side effects do occur, treatment may need to be stopped and you may get high doses of corticosteroids to suppress your immune system.

Treatment of Bladder Cancer, by Stage

Most of the time, initial treatment of bladder cancer is based on the tumor’s clinical stage, which is how deep it is thought to have grown into the bladder wall and whether it has spread beyond the bladder. Other factors, such as the size and grade of the tumor and a person’s overall health, can also affect treatment options.

Treating stage 0 bladder cancer

Stage 0 bladder cancer includes non-invasive papillary carcinoma (Ta) and flat non-invasive carcinoma (Tis). In either case, the cancer has not invaded the bladder wall beyond the inner layer.

This early stage of bladder cancer is most often treated with transurethral resection (TURBT). This may be followed either by observation (close follow-up without further treatment) or by intravesical therapy to try to keep the cancer from coming back.

Of the intravesical treatments, immunotherapy with Bacille-Calmette Guerin (BCG) seems to be better than chemotherapy at both keeping cancers from coming back and from getting worse. But it also tends to have more side effects.

Stage 0 bladder cancers rarely need to be treated with more extensive surgery. Cystectomy (removal of the bladder) is considered only when there are many superficial cancers or when a superficial cancer continues to grow (or seems to be spreading) despite treatment.

Stage 0a

For low-grade non-invasive papillary (Ta) tumors, the options after TURBT include observation, a single dose of intravesical chemotherapy (usually with mitomycin) within a day of surgery, or weekly intravesical chemo, starting a few weeks after surgery. If the cancer comes back, the treatments can be repeated.

High-grade non-invasive papillary (Ta) tumors are more likely to come back after treatment, so intravesical Bacille-Calmette Guerin (BCG) is often recommended after surgery. Another option is intravesical chemotherapy with mitomycin. Either one is usually started several weeks after surgery and is given every week for several weeks. A third option is close observation without intravesical treatment.

Stage 0is

For flat non-invasive (Tis) tumors, BCG is the treatment of choice after surgery. Patients with these tumors often get 6 weekly treatments of intravesical BCG, starting a few weeks after TUR. Some doctors recommend repeating BCG treatment every 3 to 6 months.

Follow-up and outlook after treatment

After treatment for any stage 0 cancer, close follow-up is recommended, with cystoscopy about every 3 to 6 months for a least a couple of years to look for signs of the cancer coming back or for new bladder tumors.

The outlook for people with stage 0a (non-invasive papillary) bladder cancer is excellent. These cancers are nearly always cured with treatment. During long-term follow-up care, more superficial cancers are often found in the bladder or elsewhere in the urinary system. Although these new cancers do need to be treated, they rarely are deeply invasive or life threatening.

The long-term outlook for stage 0is (flat non-invasive) bladder cancer is not quite as good as for stage 0a cancers. These cancers have a higher risk of coming back, and may return as a more serious cancer that is growing into deeper layers of the bladder or has spread to other tissues.

Treating stage I bladder cancer

Stage I bladder cancers have grown into the connective tissue layer of the bladder wall but have not reached the muscle layer.

Transurethral resection (TURBT) is typically the first treatment for these cancers, but it is done to help determine the extent of the cancer rather than to try to cure it. If no other treatment is given, many patients will later get a new bladder cancer, which will often be more advanced. This is more likely to happen if the first cancer is high grade.

Even if the cancer is found to be low grade, a second TURBT is often recommended several weeks later. If the doctor then feels that all of the cancer has been removed, intravesical BCG or mitomycin is usually given. (Less often, close follow-up alone might be an option.) If not all of the cancer was removed, options include either intravesical BCG or cystectomy (removal of part or all of the bladder).

If the cancer is high grade, if many tumors are present, or if the tumor is very large when it is first found, radical cystectomy may be recommended.

For people who aren’t healthy enough for a cystectomy, radiation therapy (often along with chemo) might be an option for treatment, although the chances for cure might not be as good.

Treating stage II bladder cancer

These cancers have invaded the muscle layer of the bladder wall. Transurethral resection (TURBT) is typically the first treatment for these cancers, but it is done to help determine the extent of the cancer rather than to try to cure it.

When the cancer has invaded the muscle, radical cystectomy (removal of the bladder) is the standard treatment. Lymph nodes near the bladder are often removed as well. If cancer is in only one part of the bladder, some patients can be treated with a partial cystectomy instead. Only a small number of patients are good candidates for this.

Although at this stage the cancer has not been detected outside the bladder, in some cases there may already be tiny deposits of cancer growing elsewhere in the body. For this reason, chemotherapy is often given either before surgery (neoadjuvant chemo) or after surgery (adjuvant chemo) to lower the chance the cancer will come back.

Many doctors prefer to give chemo before surgery because it has been shown to help patients live longer than surgery alone. When chemo is given first, surgery is delayed. This is not a problem if the chemo shrinks the bladder cancer, but it might be harmful if the tumor continues to grow during chemo.

Another option for some patients may be a second (and more extensive) transurethral resection (TURBT), followed by radiation and chemotherapy. Some people may prefer this because it lets them keep their bladder, but it’s not clear if the outcomes are as good as they are after cystectomy, so not all doctors agree with this approach. If this treatment is used you will need frequent and careful follow-up exams. Some experts recommend a repeat cystoscopy and biopsy during treatment with chemo and radiation. If cancer is found in the biopsy sample, a cystectomy will likely be needed.

For patients who can’t have a major operation because of other serious health problems, TURBT, radiation, chemotherapy, or some combination of these may options.

Treating stage III bladder cancer

These cancers have reached the outside of the bladder and might have grown into nearby tissues or organs.

Transurethral resection (TURBT) is typically done first to help determine how far the cancer has grown. Radical cystectomy (removal of the bladder and nearby lymph nodes) is then the standard treatment. Partial cystectomy is seldom an option for stage III cancers.

Neoadjuvant chemotherapy (chemo) is often given before surgery. It can shrink the tumor, which may make surgery easier. This can be especially useful for T4a tumors, which have grown outside the bladder. The chemo may also kill any cancer cells that could already have spread to other areas of the body. This approach helps patients live longer than cystectomy alone. When chemo is given first, surgery to remove the bladder is delayed. The delay is not a problem if the chemo causes the bladder cancer to shrink, but it can be harmful if the tumor continues to grow during chemotherapy.

Some patients get chemo after surgery (adjuvant treatment) to kill any areas of cancer cells left after surgery that are too small to see. Chemo given after cystectomy may help patients stay cancer-free longer, but so far it’s not clear if it helps them live longer.

An option for some patients with single, small tumors might be treatment with a second (and more extensive) transurethral resection (TURBT) followed by a combination of chemotherapy and radiation. If this isn’t successful and cancer is found when cystoscopy is repeated, the patient might need cystectomy.

For patients who can’t have a major operation because of other serious health problems, treatment options might include TURBT, radiation, chemotherapy, immunotherapy, or some combination of these.

Treating stage IV bladder cancer

These cancers have reached the abdominal or pelvic wall (T4b tumors) or have spread to nearby lymph nodes or distant parts of the body. Stage IV cancers are very hard to get rid of completely.

In most cases surgery (even radical cystectomy) can’t remove all of the cancer, so treatment is usually aimed at slowing the cancer’s growth and spread to help you live longer and feel better. If you and your doctor discuss surgery as treatment option, be sure you understand the goal of the operation – whether it is to try to cure the cancer, to help you live longer, or to help prevent or relieve symptoms from the cancer – before deciding on treatment.

For stage IV bladder cancers that have not spread to distant sites, chemotherapy (with or without radiation) is usually the first treatment. If the cancer shrinks in response to treatment, a cystectomy might be an option. Patients who can’t tolerate chemo (because of other health problems) might be treated with radiation therapy or with an immunotherapy drug such as atezolizumab or pembrolizumab.

For stage IV bladder cancers that have spread to distant areas, chemo is usually the first treatment, sometimes along with radiation therapy. Patients who can’t tolerate chemo (because of other health problems) might be treated with radiation therapy or with an immunotherapy drug such as atezolizumab or pembrolizumab. Urinary diversion without cystectomy is sometimes done to prevent or relieve a blockage of urine that could otherwise cause severe kidney damage.

Because treatment is unlikely to cure these cancers, taking part in a clinical trial may offer you access to newer forms of treatment that might help you live longer or relieve symptoms.

Treating bladder cancer that progresses or recurs

If cancer continues to grow during treatment (progresses) or comes back (recurs), your treatment options will depend on where and how much the cancer has spread, what treatments you have already had, and on your health and desire for more treatment. It’s important that you understand the goal of any further treatment – if it’s to try to cure the cancer, to slow its growth, or to help relieve symptoms – as well as the likelihood of benefits and risks.

For example, non-invasive bladder cancer often comes back in the bladder. The new cancer may be found either in the same site as the original cancer or at other sites in the bladder. These tumors are often treated the same way as the first tumor. But if the tumor keeps coming back, the patient may need a cystectomy (removal of the bladder) at some point.

Cancers that recur in distant parts of the body can be harder to remove with surgery and might require other treatments, such as chemotherapy, immunotherapy, or radiation therapy. For more on dealing with a recurrence, see the website section Understanding Recurrence.

At some point, it may become clear that standard treatments are no longer controlling the cancer. If you want to continue getting treatment, you might think about taking part in a clinical trial of newer bladder cancer treatments. While these are not always the best option for every person, they may benefit you as well as future patients.

Can you lower your risk of the cancer progressing or coming back ?

If you have (or have had) bladder cancer, you probably want to know if there are things you can do that might lower your risk of the cancer growing or coming back, such as exercising, eating a certain type of diet, or taking nutritional supplements.

Unfortunately, it’s not yet clear if there are things you can do that will help. But because bladder cancer often comes back or new bladder cancers develop, this is an active area of study. Clinical trials are now looking to see if certain vitamins, minerals, dietary supplements, or medicines might lower the risk of bladder cancer returning.

Adopting healthy behaviors such as not smoking, eating well, being active, and staying at a healthy weight might help as well, but no one knows for sure. However, we do know that these types of changes can have positive effects on your health that can extend beyond your risk of cancer.

About dietary supplements

So far, no dietary supplements (including vitamins, minerals, and herbal products) have been shown to clearly help lower the risk of bladder cancer progressing or coming back. This doesn’t mean that no supplements will help, but it’s important to know that none have been proven to do so.

Dietary supplements are not regulated like medicines in the United States – they do not have to be proven effective (or even safe) before being sold, although there are limits on what they’re allowed to claim they can do. If you are thinking about taking any type of nutritional supplement, talk to your health care team. They can help you decide which ones you can use safely while avoiding those that might be harmful.

If the cancer comes back

If your cancer does come back at some point, your treatment options will depend on the location of the cancer and what treatments you’ve had before. Options might include surgery, intravesical therapy, radiation therapy, chemotherapy, immunotherapy, or some combination of these.

Could you get a second cancer after bladder cancer treatment ?

People who’ve had bladder cancer can still get other cancers. In fact, bladder cancer survivors are at higher risk for getting some other types of cancer.

Second Cancers After Bladder Cancer

Cancer survivors can be affected by a number of health problems, but often a major concern is facing cancer again. If a cancer comes back after treatment it is called a recurrence. But some cancer survivors may develop a new, unrelated cancer later. This is called a second cancer.

Unfortunately, being treated for bladder cancer doesn’t mean you can’t get another cancer. People who have had bladder cancer can still get the same types of cancers that other people get. In fact, they might be at higher risk for certain types of cancer.

Survivors of bladder cancer can get any type of second cancer, but they have an increased risk of certain cancers, including:

  • A second bladder cancer (This is different from the first cancer coming back.)
  • Cancer of the renal pelvis/ureter (the ureter is the tube connecting the kidney to the bladder; the part of the kidney where it attaches is called the renal pelvis)
  • Cancer of the pancreas
  • Cancer of the larynx (voice box)
  • Lung cancer
  • Vaginal cancer
  • Prostate cancer
  • Kidney cancer
  • Acute myeloid leukemia (AML)

Many of these cancers are linked to smoking, which is a major risk factor for bladder cancer.

Follow-up after bladder cancer treatment

After completing treatment for bladder cancer, you should see your doctor regularly. Let them know about any new symptoms or problems, because they could be caused by the cancer coming back or by a new disease or second cancer.

Bladder cancer survivors should also follow the American Cancer Society guidelines for the early detection of cancer, such as those for colorectal and lung cancer. Most experts don’t recommend any other testing to look for second cancers unless you have symptoms.

Can you lower your risk of getting a second cancer ?

There are steps you can take to lower your risk and stay as healthy as possible. For example, it’s important to stay away from tobacco products. Smoking increases the risk of some of the second cancers seen after bladder cancer, as well as many other cancers.

To help maintain good health, bladder cancer survivors should also:

  • Get to and stay at a healthy weight
  • Stay physically active
  • Eat a healthy diet, with an emphasis on plant foods
  • Limit alcohol to no more than 1 drink per day for women or 2 per day for men

These steps may also lower the risk of some other health problems.

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  3. Gangopadhyaya AN, Upadhyaya VD, Pandey A, Gupta DK, Gopal SC, Sharma SP, et al. Single system ectopic ureter in females: A single center study. J Indian Assoc Pediatr Surg 2007;12:202-5. http://www.jiaps.com/text.asp?2007/12/4/202/40835[]
  4. Blane CE, Ritchey ML, DiPietro MA, Sumida R, Bloom DA. Single system ectopic ureters and ureteroceles associated with dysplastic kidneys. Pediatr Radiol 1992;27:491-6.[]
  5. Ahmed S, Barker A. Single system ectopic ureters: A review of 12 cases. J Paediatr Surg 1992;27:491-6.[]
  6. Chowdhary SK, Lander A, Parashar K, Corkery JJ. Single-system ectopic ureter; a 15 – year review. Pediatr Surg Int 2001;17:638-41. https://www.ncbi.nlm.nih.gov/pubmed/11727057[]
  7. McSynder H. Anomalies of the ureters. In: Gillenwater JY, Howards SS, Duckett JW, editors. Adult and pediatric urology. St. Louis: Mosby year book; 1991. p. 1831-62.[]
  8. Blane CE, Ritchey ML, DiPietro MA, Sumida R, Bloom DA. Single system ectopic ureters and ureteroceles associated with dysplastic kidneys. Pediatr Radiol 1992;22:217-20. https://link.springer.com/article/10.1007%2FBF02012501[]
  9. McSynder H. Anomalies of the ureter. In : Gillenwater JY, Howards SS, Duckett JW, editors. Adult and pediatric urology. St. Louis: Mosby Year Book; 1991. p. 1831-62.[]
  10. Mandal SN, Jagadheesan GP, Kamal MR, Mukherjee S, Das RK, Karmakar D. Bilateral Single Ectopic Ureters Draining Into a Grossly Dilated Vagina in an Adolescent Female. Korean Journal of Urology. 2013;54(7):482-485. doi:10.4111/kju.2013.54.7.482. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3715714/[]
  11. Thomas DF, Fitzpatrick MM. Unilateral multicystic dysplastic kidney. Arch Dis Child 1997;77:368-9. https://www.ncbi.nlm.nih.gov/pubmed/9389248[]
  12. Occult bilateral ectopic vaginal ureters causing urinary incontinence: diagnosis by computed tomography. Pantuck AJ, Barone JG, Rosenfeld DL, Fleisher MH. Abdom Imaging. 1996 Jan-Feb; 21(1):78-80. https://www.ncbi.nlm.nih.gov/pubmed/8672982/[]
  13. Vesical continence in bilateral ectopic single ureters. Podestà E, Scarsi PL, Di Rovasenda E, Ferretti S, Magillo P, Dodero P. J Urol. 2001 Jun; 165(6 Pt 2):2363-5. https://www.ncbi.nlm.nih.gov/pubmed/11371979/[]
  14. Ahmed SA, Barker A. Single system ectopic ureters: A review of 12 cases. J Pediatr Surg 1992;27:491-6.[]
  15. Borer JG, Bauer SB, Peters CA, Diamond DA, Decler RM, Shapiro EA. A single system ectopic ureter draining an ectopic dysplastic kidney: Delayed diagnosis in the young female with continuous urinary incontinence. Br J Urol 1998;81:474-8.[]
  16. Wunsch L, Hubner U, Halsband H. Long-term results of treatment of single-system ectopic ureters. Pediatr Surg Int 2000;16:493-7.[]
  17. Spectrum of ectopic ureters in children. Pediatr Surg Int. 2008 Jul;24(7):819-23. doi: 10.1007/s00383-008-2172-2. Epub 2008 May 8. https://www.ncbi.nlm.nih.gov/pubmed/18463883[][]
  18. Roupret M, Babjuk M, Comperat E, Zigeuner R, Sylvester RJ, Burger M, Cowan NC, Bohle A, Van Rhijn BW, Kaasinen E, Palou J, Shariat SF. European Association of Urology guidelines on upper urinary tract urothelial cell carcinoma: 2015 update. Eur Urol. 2015;68:868–879. https://www.ncbi.nlm.nih.gov/pubmed/26188393[]
  19. Surveillance, Epidemiology, and End Results Program. https://seer.cancer.gov/ []
  20. Gakis G, Black PC, Bochner BH, Boorjian SA, Stenzl A, Thalmann GN, Kassouf W. Systematic review on the fate of the remnant urothelium after radical cystectomy. Eur Urol. 2017;71:545–557. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5533286/[]
  21. Prognostic factors and outcomes of primary transitional cell carcinoma of the ureter: a population-based study. Oncotarget. 2017 Sep 12; 8(39): 65983–65996. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5630387/[]
  22. Lughezzani G, Burger M, Margulis V, Matin SF, Novara G, Roupret M, Shariat SF, Wood CG, Zigeuner R. Prognostic factors in upper urinary tract urothelial carcinomas: a comprehensive review of the current literature. Eur Urol. 2012;62:100–114. https://www.ncbi.nlm.nih.gov/pubmed/22381168[]
  23. Clark PE, Spiess PE, Agarwal N, Bangs R, Boorjian SA, Buyyounouski MK, Efstathiou JA, Flaig TW, Friedlander T, Greenberg RE, Guru KA, Hahn N, Herr HW, et al. NCCN Guidelines insights: bladder cancer, version 2.2016. J Natl Compr Canc Netw. 2016;14:1213–1224. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5379654/[]
  24. Upper urinary tract disease: what we know today and unmet needs. Mathieu R, Bensalah K, Lucca I, Mbeutcha A, Rouprêt M, Shariat SF. Transl Androl Urol. 2015 Jun; 4(3):261-72. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4708228/[]
  25. Oncological outcomes after radical nephroureterectomy for upper tract urothelial carcinoma: comparison over the three decades. Adibi M, Youssef R, Shariat SF, Lotan Y, Wood CG, Sagalowsky AI, Zigeuner R, Montorsi F, Bolenz C, Margulis V. Int J Urol. 2012 Dec; 19(12):1060-6. https://www.ncbi.nlm.nih.gov/pubmed/22882743/[]
  26. Neoadjuvant and adjuvant chemotherapy use in upper tract urothelial carcinoma. Cohen A, Kuchta K, Park S. Urol Oncol. 2017 Jun; 35(6):322-327. https://www.ncbi.nlm.nih.gov/pubmed/28065502/[]
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12 Body SystemsBladderUrinary System

Urinary bladder

bladder anatomy

Urinary bladder

The urinary bladder is a hollow, collapsible muscular sac that stores and expels urine situated in the pelvic cavity posterior to the pubic symphysis. In males, it is
directly anterior to the rectum; in females, it is anterior to the vagina and inferior to the uterus (see Figure 1). Folds of the peritoneum hold the urinary bladder in position. When slightly distended due to the accumulation of urine, the urinary bladder is spherical. When it is empty, it collapses. As urine volume increases, it becomes pear shaped and rises into the abdominal cavity.

Urinary bladder capacity averages 700–800 mL. It is smaller in females because the uterus occupies the space just superior to the urinary bladder.

Anatomy of the Urinary Bladder

In the floor of the urinary bladder is a small triangular area called the trigone. The two posterior corners of the trigone contain the two ureteral openings; the opening into the urethra, the internal urethral orifice, lies in the anterior corner (see Figure 2). Because its mucosa is firmly bound to the muscularis, the trigone has a smooth appearance. Three coats make up the wall of the urinary bladder. The deepest is the mucosa, a mucous membrane composed of transitional epithelium and an underlying lamina propria similar to that of the ureters. The transitional epithelium permits stretching. Rugae (the folds in the mucosa) are also present to permit expansion of the urinary bladder. Surrounding the mucosa is the intermediate muscularis, also called the detrusor muscle (to push down),
which consists of three layers of smooth muscle fibers: the inner longitudinal, middle circular, and outer longitudinal layers. Around the opening to the urethra the circular fibers form an internal urethral sphincter; inferior to it is the external urethral sphincter, which is composed of skeletal muscle and is a modification of the deep muscles of the perineum. The most superficial coat of the urinary bladder on the posterior and inferior surfaces is the adventitia, a layer of areolar connective tissue that is continuous with that of the ureters. Over the superior surface of the urinary bladder is the serosa, a layer of visceral peritoneum.

Figure 1. Anatomy of the male urinary system

male urinary system anatomy

Figure 2. Anatomy of the female urinary system

Anatomy of the female urinary system

Figure 3. Urinary bladder location

urinary bladder location

Figure 4. Urinary bladder anatomy

bladder anatomy

Voiding Urine

Discharge of urine from the urinary bladder, called micturition, is also known as urination or voiding. Micturition occurs via a combination of involuntary and voluntary muscle contractions. When the volume of urine in the urinary bladder exceeds 200–400 mL, pressure within the bladder increases considerably, and stretch receptors in its wall transmit nerve impulses into the spinal cord. These impulses propagate to the micturition center in sacral spinal cord segments S2 and S3 and trigger a spinal reflex called the micturition reflex. In this reflex arc, parasympathetic impulses from the micturition center propagate to the urinary bladder wall and internal urethral sphincter.

The nerve impulses cause contraction of the detrusor muscle and relaxation of the internal urethral sphincter muscle. Simultaneously, the micturition center inhibits somatic motor neurons that innervate skeletal muscle in the external urethral sphincter. On contraction of the urinary bladder wall and relaxation of the sphincters, urination takes place. Urinary bladder filling causes a sensation of fullness that initiates a conscious desire to urinate before the micturition reflex actually occurs. Although emptying of the urinary bladder is a reflex, in early childhood we learn to initiate it and stop it voluntarily.

Through learned control of the external urethral sphincter muscle and certain muscles of the pelvic floor, the cerebral cortex can initiate micturition or delay its occurrence for a limited period.

Figure 5. Bladder control

neural control of urination

Bladder Control Problems in Men (Urinary Incontinence)

Urinary incontinence is the loss of bladder control, resulting in the accidental leakage of urine from the body 1. For example, a man may feel a strong, sudden need, or urgency, to urinate just before losing a large amount of urine, called urgency incontinence.

Urinary incontinence can be slightly bothersome or totally debilitating. For some men, the chance of embarrassment keeps them from enjoying many activities, including exercising, and causes emotional distress. When people are inactive, they increase their chances of developing other health problems, such as obesity and diabetes.

How common is urinary incontinence in men ?

Urinary incontinence occurs in 11 to 34 percent of older men. Two to 11 percent of older men report daily urinary incontinence 2. Although more women than men develop urinary incontinence, the chances of a man developing urinary incontinence increase with age because he is more likely to develop prostate problems as he ages. Men are also less likely to speak with a health care professional about urinary incontinence, so urinary incontinence in men is probably far more common than statistics show. Having a discussion with a health care professional about urinary incontinence is the first step to fixing this treatable problem.

What causes urinary incontinence in men ?

Urinary incontinence in men results when the brain does not properly signal the bladder, the sphincters do not squeeze strongly enough, or both. The bladder muscle may contract too much or not enough because of a problem with the muscle itself or the nerves controlling the bladder muscle. Damage to the sphincter muscles themselves or the nerves controlling these muscles can result in poor sphincter function. These problems can range from simple to complex.

A man may have factors that increase his chances of developing urinary incontinence, including:

  • birth defects—problems with development of the urinary tract
  • a history of prostate cancer—surgery or radiation treatment for prostate cancer can lead to temporary or permanent urinary incontinence in men

Urinary incontinence is not a disease. Instead, it can be a symptom of certain conditions or the result of particular events during a man’s life. Conditions or events that may increase a man’s chance of developing urinary incontinence include:

  • Benign prostatic hyperplasia—a condition in which the prostate is enlarged yet not cancerous. In men with benign prostatic hyperplasia, the enlarged prostate presses against and pinches the urethra. The bladder wall becomes thicker. Eventually, the bladder may weaken and lose the ability to empty, leaving some urine in the bladder. The narrowing of the urethra and incomplete emptying of the bladder can lead to urinary incontinence.
  • Chronic coughing—long-lasting coughing increases pressure on the bladder and pelvic floor muscles.
  • Neurological problems—men with diseases or conditions that affect the brain and spine may have trouble controlling urination.
  • Physical inactivity—decreased activity can increase a man’s weight and contribute to muscle weakness.
  • Obesity—extra weight can put pressure on the bladder, causing a need to urinate before the bladder is full.
  • Older age—bladder muscles can weaken over time, leading to a decrease in the bladder’s capacity to store urine.

What are the types of urinary incontinence in men ?

The types of urinary incontinence in men include:

  • Urgency incontinence
  • Stress incontinence
  • Functional incontinence
  • Overflow incontinence
  • Transient incontinence

Urgency Incontinence

Urgency incontinence happens when a man urinates involuntarily after he has a strong desire, or urgency, to urinate. Involuntary bladder contractions are a common cause of urgency incontinence. Abnormal nerve signals might cause these bladder contractions.

Triggers for men with urgency incontinence include drinking a small amount of water, touching water, hearing running water, or being in a cold environment—even if for just a short while—such as reaching into the freezer at the grocery store. Anxiety or certain liquids, medications, or medical conditions can make urgency incontinence worse.

The following conditions can damage the spinal cord, brain, bladder nerves, or sphincter nerves, or can cause involuntary bladder contractions leading to urgency incontinence:

  • Alzheimer’s disease—a disorder that affects the parts of the brain that control thought, memory, and language
  • Injury to the brain or spinal cord that interrupts nerve signals to and from the bladder
  • Multiple sclerosis—a disease that damages the material that surrounds and protects nerve cells, which slows down or blocks messages between the brain and the body
  • Parkinson’s disease—a disease in which the cells that make a chemical that controls muscle movement are damaged or destroyed
  • Stroke—a condition in which a blocked or ruptured artery in the brain or neck cuts off blood flow to part of the brain and leads to weakness, paralysis, or problems with speech, vision, or brain function

Urgency incontinence is a key sign of overactive bladder. Overactive bladder occurs when abnormal nerves send signals to the bladder at the wrong time, causing its muscles to squeeze without enough warning time to get to the toilet.

Stress Incontinence

Stress incontinence results from movements that put pressure on the bladder and cause urine leakage, such as coughing, sneezing, laughing, or physical activity. In men, stress incontinence may also occur:

  • after prostate surgery
  • after neurologic injury to the brain or spinal cord
  • after trauma, such as injury to the urinary tract
  • during older age

Functional Incontinence

Functional incontinence occurs when physical disability, external obstacles, or problems in thinking or communicating keep a person from reaching a place to urinate in time. For example, a man with Alzheimer’s disease may not plan ahead for a timely trip to a toilet. A man in a wheelchair may have difficulty getting to a toilet in time. Arthritis—pain and swelling of the joints—can make it hard for a man to walk to the restroom quickly or open his pants in time.

Overflow Incontinence

When the bladder doesn’t empty properly, urine spills over, causing overflow incontinence. Weak bladder muscles or a blocked urethra can cause this type of incontinence. Nerve damage from diabetes or other diseases can lead to weak bladder muscles; tumors and urinary stones can block the urethra. Men with overflow incontinence may have to urinate often, yet they release only small amounts of urine or constantly dribble urine.

Transient Incontinence

Transient incontinence is urinary incontinence that lasts a short time. Transient incontinence is usually a side effect of certain medications, drugs, or temporary conditions, such as:

  • Urinary tract infection, which can irritate the bladder and cause strong urges to urinate
  • Caffeine or alcohol consumption, which can cause rapid filling of the bladder
  • Chronic coughing, which can put pressure on the bladder
  • Constipation—hard stool in the rectum can put pressure on the bladder
  • Blood pressure medications that can cause increased urine production
  • Short-term mental impairment that reduces a man’s ability to care for himself
  • Short-term restricted mobility

How is urinary incontinence in men diagnosed ?

Men should tell a health care professional, such as a family practice physician, a nurse, an internist, or a urologist—a doctor who specializes in urinary problems—they have urinary incontinence, even if they feel embarrassed. To diagnose urinary incontinence, the health care professional will:

  • take a medical history
  • conduct a physical exam
  • order diagnostic tests

Medical History

Taking a medical history can help a health care professional diagnose urinary incontinence. He or she will ask the patient or caretaker to provide a medical history, a review of symptoms, a description of eating habits, and a list of prescription and over-the-counter medications the patient is taking. The health care professional will ask about current and past medical conditions.

The health care professional also will ask about the man’s pattern of urination and urine leakage. To prepare for the visit with the health care professional, a man may want to keep a bladder diary for several days beforehand. Information that a man should record in a bladder diary includes:

  • the amount and type of liquid he drinks
  • how many times he urinates each day and how much urine is released
  • how often he has accidental leaks
  • whether he felt a strong urge to go before leaking
  • what he was doing when the leak occurred, for example, coughing or lifting
  • how long the symptoms have been occurring

The health care professional also may ask about other lower urinary tract symptoms that may indicate a prostate problem, such as:

  • problems starting a urine stream
  • problems emptying the bladder completely
  • spraying urine
  • dribbling urine
  • weak stream
  • recurrent urinary tract infections
  • painful urination

Physical Exam

A physical exam may help diagnose urinary incontinence. The health care professional will perform a physical exam to look for signs of medical conditions that may cause urinary incontinence. The health care professional may order further neurologic testing if necessary.

Digital rectal exam. The health care professional also may perform a digital rectal exam. A digital rectal exam is a physical exam of the prostate and rectum. To perform the exam, the health care professional has the man bend over a table or lie on his side while holding his knees close to his chest. The health care professional slides a gloved, lubricated finger into the patient’s rectum and feels the part of the prostate that lies in front of the rectum. The digital rectal exam is used to check for stool or masses in the rectum and to assess whether the prostate is enlarged or tender, or has other abnormalities. The health care professional may perform a prostate massage during a digital rectal exam to collect a sample of prostate fluid that he or she can test for signs of infection.

The health care professional may diagnose the type of urinary incontinence based on the medical history and physical exam, or he or she may use the findings to determine if a man needs further diagnostic testing.

Diagnostic Tests

The health care professional may order one or more of the following diagnostic tests based on the results of the medical history and physical exam:

  • Urinalysis. Urinalysis involves testing a urine sample. The patient collects a urine sample in a special container at home, at a health care professional’s office, or at a commercial facility. A health care professional tests the sample during an office visit or sends it to a lab for analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color to indicate signs of infection in urine.
  • Urine culture. A health care professional performs a urine culture by placing part of a urine sample in a tube or dish with a substance that encourages any bacteria present to grow. A man collects the urine sample in a special container in a health care professional’s office or a commercial facility. The office or facility tests the sample onsite or sends it to a lab for culture. A health care professional can identify bacteria that multiply, usually in 1 to 3 days. A health care professional performs a urine culture to determine the best treatment when urinalysis indicates the man has a urinary tract infection.
  • Blood test. A blood test involves drawing blood at a health care professional’s office or a commercial facility and sending the sample to a lab for analysis. The blood test can show kidney function problems or a chemical imbalance in the body. The lab also will test the blood to assess the level of prostate-specific antigen, a protein produced by prostate cells that may be higher in men with prostate cancer.
  • Urodynamic testing. Urodynamic testing includes a variety of procedures that look at how well the bladder and urethra store and release urine. A health care professional performs urodynamic tests during an office visit or in an outpatient center or a hospital. Some urodynamic tests do not require anesthesia; others may require local anesthesia. Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely; they may include the following:
    + uroflowmetry, which measures how rapidly the bladder releases urine
    + postvoid residual measurement, which evaluates how much urine remains in the bladder after urination
    + reduced urine flow or residual urine in the bladder, which often suggests urine blockage due to benign prostatic hyperplasia

How is urinary incontinence in men treated ?

Treatment depends on the type of urinary incontinence.

Urgency Incontinence

As a first line of therapy for urgency incontinence, a health care professional may recommend the following techniques to treat a man’s problem:

  • behavioral and lifestyle changes
  • bladder training
  • pelvic floor exercises
  • urgency suppression

If those treatments are not successful, the following additional measures may help urgency incontinence:

  • medications
  • electrical nerve stimulation
  • bulking agents
  • surgery

A health care professional may recommend other treatments for men with urgency incontinence caused by Benign Prostatic Hyperplasia.

Behavioral and lifestyle changes. Men with urgency incontinence may be able to reduce leaks by making behavioral and lifestyle changes:

  • Eating, diet, and nutrition. Men with urgency incontinence can change the amount and type of liquid they drink. A man can try limiting bladder irritants—including caffeinated drinks such as tea or coffee and carbonated beverages—to decrease leaks. Men also should limit alcoholic drinks, which can increase urine production. A health care professional can help a man determine how much he should drink based on his health, how active he is, and where he lives. To decrease nighttime trips to the restroom, men may want to stop drinking liquids several hours before bed.
  • Engaging in physical activity. Although a man may be reluctant to engage in physical activity when he has urgency incontinence, regular exercise is important for good overall health and for preventing and treating urinary incontinence.
  • Losing weight. Men who are overweight should talk with a health care professional about strategies for losing weight, which can help improve urinary incontinence.
  • Preventing constipation. Gastrointestinal (GI) problems, especially constipation, can make urinary tract health worse and can lead to urinary incontinence. The opposite is also true: Urinary problems, such as urinary incontinence, can make gastrointestinal problems worse.

To Help Prevent Bladder Problems, Stop Smoking

People who smoke should stop. Quitting smoking at any age promotes bladder health and overall health. Smoking increases a person’s chance of developing stress incontinence, as it increases coughing. Some people say smoking worsens their bladder irritation. Smoking causes most cases of bladder cancer. People who smoke for many years have a higher risk of bladder cancer than nonsmokers or those who smoke for a short time 3.

Bladder training. Bladder training is changing urination habits to decrease incidents of urinary incontinence. The health care professional may suggest a man use the restroom at regular timed intervals, called timed voiding, based on the man’s bladder diary. A man can gradually lengthen the time between trips to the restroom to help stretch the bladder so it can hold more urine.

Pelvic floor muscle exercises. Pelvic floor muscle, or Kegel, exercises involve strengthening pelvic floor muscles. Strong pelvic floor muscles hold in urine more effectively than weak muscles. A man does not need special equipment for Kegel exercises. The exercises involve tightening and relaxing the muscles that control urine flow. Pelvic floor exercises should not be performed during urination.

Men also may learn how to perform Kegel exercises properly by using biofeedback. Biofeedback uses special sensors to measure bodily functions, such as muscle contractions that control urination. A video monitor displays the measurements as graphs, and sounds indicate when the man is using the correct muscles. The health care professional uses the information to help the man change abnormal function of the pelvic floor muscles. At home, the man practices to improve muscle function. The man can perform the exercises while lying down, sitting at a desk, or standing up. Success with pelvic floor exercises depends on the cause of urinary incontinence, its severity, and the man’s ability to perform the exercises.

Urgency suppression. By using certain techniques, a man can suppress the urge to urinate, called urgency suppression. Urgency suppression is a way for a man to train his bladder to maintain control so he does not have to panic about finding a restroom. Some men use distraction techniques to take their mind off the urge to urinate. Other men find taking long, relaxing breaths and being still can help. Doing pelvic floor exercises also can help suppress the urge to urinate.

Medications. Health care professionals may prescribe medications that relax the bladder, decrease bladder spasms, or treat prostate enlargement to treat urgency incontinence in men.

Antimuscarinics. Antimuscarinics can help relax bladder muscles and prevent bladder spasms. These medications include oxybutynin (Oxytrol), tolterodine (Detrol), darifenacin (Enablex), trospium (Sanctura), fesoterodine (Toviaz), and solifenacin (VESIcare). They are available in pill, liquid, and patch form.

Tricyclic antidepressants. Tricyclic antidepressants such as imipramine (Tofranil) can calm nerve signals, decreasing spasms in bladder muscles.

Alpha-blockers. Terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Uroxatral), and silodosin (Rapaflo) are used to treat problems caused by prostate enlargement and bladder outlet obstruction. These medications relax the smooth muscle of the prostate and bladder neck, which lets urine flow normally and prevents abnormal bladder contractions that can lead to urgency incontinence.

5-alpha reductase inhibitors. Finasteride (Proscar) and dutasteride (Avodart) block the production of the male hormone dihydrotestosterone, which accumulates in the prostate and may cause prostate growth. These medications may help to relieve urgency incontinence problems by shrinking an enlarged prostate.

Beta-3 agonists. Mirabegron (Myrbetriq) is a beta-3 agonist a person takes by mouth to help prevent symptoms of urgency incontinence. Mirabegron suppresses involuntary bladder contractions.

Botox. A health care professional may use onabotulinumtoxinA (Botox), also called botulinum toxin type A, to treat urinary incontinence in men with neurological conditions such as spinal cord injury or multiple sclerosis. Injecting Botox into the bladder relaxes the bladder, increasing storage capacity and decreasing urinary incontinence. A health care professional performs the procedure during an office visit. A man receives local anesthesia. The health care professional uses a cystoscope to guide the needle for injecting the Botox. Botox is effective for up to 10 months.

Electrical nerve stimulation. If behavioral and lifestyle changes and medications do not improve symptoms, a urologist may suggest electrical nerve stimulation as an option to prevent urinary incontinence, urinary frequency—urination more often than normal—and other symptoms. Electrical nerve stimulation involves altering bladder reflexes using pulses of electricity. The two most common types of electrical nerve stimulation are percutaneous tibial nerve stimulation and sacral nerve stimulation 4.

Percutaneous tibial nerve stimulation uses electrical stimulation of the tibial nerve, which is located in the ankle, on a weekly basis. The patient receives local anesthesia for the procedure. In an outpatient center, a urologist inserts a battery-operated stimulator beneath the skin near the tibial nerve. Electrical stimulation of the tibial nerve prevents bladder activity by interfering with the pathway between the bladder and the spinal cord or brain. Although researchers consider percutaneous tibial nerve stimulation safe, they continue to study the exact ways that it prevents symptoms and how long the treatment can last.

Sacral nerve stimulation involves implanting a battery-operated stimulator beneath the skin in the lower back near the sacral nerve. The procedure takes place in an outpatient center using local anesthesia. Based on the patient’s feedback, the health care professional can adjust the amount of stimulation so it works best for that individual. The electrical pulses enter the body for minutes to hours, two or more times a day, either through wires placed on the lower back or just above the pubic area—between the navel and the pubic hair. Sacral nerve stimulation may increase blood flow to the bladder, strengthen pelvic muscles that help control the bladder, and trigger the release of natural substances that block pain. The patient can turn the stimulator on or off at any time.

A patient may consider getting an implanted device that delivers regular impulses to the bladder. A urologist places a wire next to the tailbone and attaches it to a permanent stimulator under the skin.

Bulking agents. A urologist injects bulking agents, such as collagen and carbon spheres, near the urinary sphincter to treat incontinence. The bulking agent makes the tissues thicker and helps close the bladder opening. Before the procedure, the health care professional may perform a skin test to make sure the man doesn’t have an allergic reaction to the bulking agent. A urologist performs the procedure during an office visit. The man receives local anesthesia. The urologist uses a cystoscope—a tubelike instrument used to look inside the urethra and bladder—to guide the needle for injection of the bulking agent. Over time, the body may slowly eliminate certain bulking agents, so a man may need to have injections again.

Surgery. As a last resort, surgery to treat urgency incontinence in men includes the artificial urinary sphincter (AUS) and the male sling. A health care professional performs the surgery in a hospital with regional or general anesthesia. Most men can leave the hospital the same day, although some may need to stay overnight.

Artificial urinary sphincter. An artificial urinary sphincter is an implanted device that keeps the urethra closed until the man is ready to urinate. The device has three parts: a cuff that fits around the urethra, a small balloon reservoir placed in the abdomen, and a pump placed in the scrotum—the sac that holds the testicles. The cuff contains a liquid that makes it fit tightly around the urethra to prevent urine from leaking. When it is time to urinate, the man squeezes the pump with his fingers to deflate the cuff. The liquid moves to the balloon reservoir and lets urine flow through the urethra. When the bladder is empty, the cuff automatically refills in the next 2 to 5 minutes to keep the urethra tightly closed.

Male sling. A health care professional performs a sling procedure, also called urethral compression procedure, to add support to the urethra, which can sometimes better control urination. Through an incision in the tissue between the scrotum and the rectum, also called the perineum, the health care professional uses a piece of human tissue or mesh to compress the urethra against the pubic bone. The surgeon secures the ends of the tissue or mesh around the pelvic bones. The lifting and compression of the urethra sometimes provides better control over urination.

Stress Incontinence

Men who have stress incontinence can use the same techniques for treating urgency incontinence.

Functional Incontinence

Men with functional incontinence may wear protective undergarments if they worry about reaching a restroom in time. These products include adult diapers or pads and are available from drugstores, grocery stores, and medical supply stores. Men who have functional incontinence should talk to a health care professional about its cause and how to prevent or treat functional incontinence.

Overflow Incontinence

A health care professional treats overflow incontinence caused by a blockage in the urinary tract with surgery to remove the obstruction. Men with overflow incontinence that is not caused by a blockage may need to use a catheter to empty the bladder. A catheter is a thin, flexible tube that is inserted through the urethra into the bladder to drain urine. A health care professional can teach a man how to use a catheter. A man may need to use a catheter once in a while, a few times a day, or all the time. Catheters that are used continuously drain urine from the bladder into a bag that is attached to the man’s thigh with a strap. Men using a continuous catheter should watch for symptoms of an infection.

Transient Incontinence

A health care professional treats transient incontinence by addressing the underlying cause. For example, if a medication is causing increased urine production leading to urinary incontinence, a health care professional may try lowering the dose or prescribing a different medication. A health care professional may prescribe bacteria-fighting medications called antibiotics to treat urinary tract infections.

Bladder Control Problems in Women (Urinary Incontinence)

Urinary incontinence in women results when the brain does not properly signal the bladder, the sphincters do not squeeze strongly enough, or both 5. The bladder muscle may contract too much or not enough because of a problem with the muscle itself or the nerves controlling the bladder muscle. Damage to the sphincter muscles themselves or the nerves controlling these muscles can result in poor sphincter function. These problems can range from simple to complex.

A woman may be born with factors that increase her chances of developing urinary incontinence, which include:

  • birth defects—problems with development of the urinary tract
  • genetics—a woman is more likely to have urinary incontinence if other females in her family have urinary incontinence
  • race—Caucasian women are more likely to be affected than Hispanic/Latina, African American, or Asian American women

Urinary incontinence is not a disease. Urinary incontinence can be a symptom of certain conditions or the result of certain events during a woman’s life. Conditions or events that may increase a woman’s chance of developing urinary incontinence include:

  • Childbirth—the childbirth process can damage the muscles and nerves that control urination
  • Chronic coughing—long-lasting coughing increases pressure on the bladder and pelvic floor muscles
  • Menopause—reduces production of the hormone that keeps the lining of the bladder and urethra healthy
  • Neurological problems—women with diseases or conditions that affect the brain and spine may have trouble controlling urination
  • Physical inactivity—decreased activity can increase a woman’s weight and contribute to muscle weakness
  • Obesity—extra weight can put pressure on the bladder, causing a need to urinate before the bladder is full
  • Older age—bladder muscles can weaken over time, leading to a decrease in the bladder’s capacity to store urine
  • Pelvic organ prolapse—causes sagging of the bladder, bowel, or uterus out of their normal positions
  • Pregnancy—the fetus can put pressure on the bladder during pregnancy.

How common is urinary incontinence in women ?

Research shows that 25 to 45 percent of women have some degree of urinary incontinence. In women ages 20 to 39, 7 to 37 percent report some degree of urinary incontinence. Nine to 39 percent of women older than 60 report daily urinary incontinence. Women experience urinary incontinence twice as often as men 2. Pregnancy, childbirth, menopause, and the structure of the female urinary tract account for this difference.

What are the types of urinary incontinence in women ?

The types of urinary incontinence in women include:

  • Stress incontinence
  • Urgency incontinence
  • Mixed incontinence
  • Other types of incontinence

Stress Incontinence

Stress incontinence results from movements that put pressure on the bladder and cause urine leakage, such as coughing, sneezing, laughing, or physical activity. Physical changes from pregnancy and childbirth often cause stress incontinence. Weakening of pelvic floor muscles can cause the bladder to move downward, pushing the bladder slightly out of the bottom of the pelvis and making it difficult for the sphincters to squeeze tightly enough. As a result, urine can leak during moments of physical stress. Stress incontinence can also occur without the bladder moving downward if the urethra wall is weak. This type of incontinence is common in women, and a health care professional can treat the condition.

Urgency Incontinence

Urgency incontinence is the loss of urine when a woman has a strong desire, or urgency, to urinate. Involuntary bladder contractions are a common cause of urgency incontinence. Abnormal nerve signals might cause these bladder contractions.

Triggers for women with urgency incontinence include drinking a small amount of water, touching water, hearing running water, or being in a cold environment—even if for just a short while—such as reaching into the freezer at the grocery store. Anxiety or certain liquids, medications, or medical conditions can make urgency incontinence worse.

Damage to the spinal cord or brain, the bladder nerves, or the bladder muscles may cause involuntary bladder contractions. Bladder nerves and muscles can be affected by:

  • Alzheimer’s disease—a brain disorder that affects the parts of the brain that control thought, memory, and language
    injury
  • Multiple sclerosis—a disease that damages the material that surrounds and protects nerve cells, which slows down or blocks messages between the brain and body
  • Parkinson’s disease—a disease in which cells that make a chemical that controls muscle movement are damaged or destroyed
  • Stroke—a condition in which the blood supply to the brain is suddenly cut off, caused by a blockage or the bursting of a blood vessel in the brain or neck

Urgency incontinence is a key sign of overactive bladder. Overactive bladder occurs when abnormal nerves send signals to the bladder at the wrong time, causing its muscles to squeeze without enough warning time to get to the toilet.

Mixed Incontinence

Mixed incontinence is when stress and urgency incontinence occur together.

Other Types of Incontinence

Functional incontinence occurs when physical disability, external obstacles, or problems in thinking or communicating keep a person from reaching a toilet in time. For example, a woman with Alzheimer’s disease may not plan ahead for a timely trip to a toilet. A woman in a wheelchair may have difficulty getting to a toilet in time. Arthritis—pain and swelling of the joints—can make it hard for a woman to walk to the toilet quickly or unbutton her pants in time.

Transient incontinence is urinary incontinence that lasts a short time. Transient incontinence is usually caused by medications or a temporary condition, such as:

  • a urinary tract infection (UTI)—a UTI can irritate the bladder, causing strong urges to urinate
  • caffeine or alcohol consumption—consumption of caffeine or alcohol can cause rapid filling of the bladder
  • chronic coughing—chronic coughing can put pressure on the bladder
  • constipation—hard stool in the rectum can put pressure on the bladder
  • medication—blood pressure medications can cause increased production of urine
  • short-term mental impairment
  • short-term restricted mobility

Overflow incontinence happens when the bladder doesn’t empty properly, causing it to spill over. A health care professional can check for this problem. Weak bladder muscles or a blocked urethra can cause this type of incontinence. Nerve damage from diabetes or other diseases can lead to weak bladder muscles; tumors and urinary stones can block the urethra. Overflow incontinence is rare in women.

How is urinary incontinence in women diagnosed ?

Women should let their health care provider, such as a family practice physician, a nurse, an internist, a gynecologist, urologist, or a urogynecologist—a gynecology doctor who has extra training in bladder problems and pelvic problems in women—know they have urinary incontinence, even if they feel embarrassed. To diagnose urinary incontinence, a health care professional will take a medical history and conduct a physical exam. The health care professional may order diagnostic tests, such as a urinalysis.

Medical History

The health care professional will take a medical history and ask about symptoms, patterns of urination and urine leakage, bowel function, medications, history of childbirth, and past pelvic operations. To prepare for the visit with the health care professional, a woman may want to keep a bladder diary for several days beforehand. Information that a woman should record in a bladder diary includes:

  • what and how much she drinks
  • how many times she urinates and how much urine is released
  • how often she has accidental leaks
  • whether she feels a strong urge to go before leaking
  • what she was doing when leaks occurred, for example, coughing or lifting

Physical Exam

The health care professional will also perform a limited physical exam to look for signs of medical conditions that may cause urinary incontinence. The health care professional may order further neurologic testing if necessary. The health care professional may also perform pelvic and rectal exams.

Pelvic exam. A pelvic exam is a visual and physical exam of the pelvic organs. The health care professional has the woman come to the exam with a full bladder. The woman will sit upright with her legs spread and asks her to cough. This test is called a cough stress test. Leakage of urine indicates stress incontinence. The health care professional then has the woman lie on her back on an exam table and place her feet on the corners of the table or in supports. The health care professional looks at the pelvic organs and slides a gloved, lubricated finger into the vagina to check for prolapse or other physical problems that may be causing urinary incontinence. The health care professional will determine the woman’s pelvic muscle strength by asking her to squeeze her pelvic floor muscles.

Digital rectal exam. A digital rectal exam is a physical exam of the rectum. The health care professional slides a gloved, lubricated finger into the rectum, usually during a pelvic exam. A health care professional uses the digital rectal exam to check for stool or masses in the rectum that may be causing urinary incontinence.

The health care professional may diagnose the type of urinary incontinence based on the medical history and physical exam or use this information to determine if a woman needs further diagnostic testing.

Diagnostic Tests

The health care professional may order one or both of the following diagnostic tests, based on the results of the medical history and physical exam:

Urinalysis. Urinalysis is testing of a urine sample. The patient collects the urine sample in a special container in a health care professional’s office or a commercial facility for testing and analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color when blood or protein is present in urine. A person does not need anesthesia for this test. The test can show if the woman has a urinary tract infection, a kidney problem, or diabetes.

Urine culture. A health care professional performs a urine culture by placing part of a urine sample in a tube or dish with a substance that encourages any bacteria present to grow. A woman collects the urine sample in a special container in a health care professional’s office or a commercial facility. The office or facility tests the sample onsite or sends it to a lab for culture. A health care professional can identify bacteria that multiply, usually in 1 to 3 days. A health care professional performs a urine culture to determine the best treatment when urinalysis indicates the woman has a urinary tract infection.

Blood test. A blood test involves drawing blood at a health care professional’s office or a commercial facility and sending the sample to a lab for analysis. The blood test can show problems with kidney function or a chemical imbalance in the body.

Urodynamic testing. Urodynamic testing is any procedure that looks at how well the bladder, urethra, and sphincters store and release urine. Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely.

How is urinary incontinence in women treated ?

Treatment depends on the type of urinary incontinence. Health care professionals may recommend behavioral and lifestyle changes, stopping smoking, bladder training, pelvic floor exercises, and urgency suppression as a first-line therapy for most types of urinary incontinence.

Stress Incontinence

Behavioral and lifestyle changes. Women with urinary incontinence may be able to reduce leaks by making behavioral and lifestyle changes. For example, the amount and type of liquid women drink can affect urinary incontinence. Women should talk with their health care professional about whether to drink less liquid during the day; however, women should not limit liquids to the point of becoming dehydrated.

Signs of dehydration in women include:

  • constipation
  • dark-colored urine
  • dizziness
  • dry skin
  • fatigue, or feeling tired
  • less frequent urination than usual
  • light-headedness
  • thirst

A health care professional can help a woman determine how much she should drink to prevent dehydration based on her health, how active she is, and where she lives.

To decrease nighttime trips to the bathroom, women may want to stop drinking liquids several hours before bedtime if suggested by a health care professional.

Limiting bladder irritants—including caffeinated drinks such as tea or coffee and carbonated beverages—may decrease leaks. Women should also limit alcoholic drinks, which can increase urine production.

Although a woman may be reluctant to engage in physical activity when she has urinary incontinence, regular exercise is important for weight management and good overall health. Losing weight may improve urinary incontinence and not gaining weight may prevent urinary incontinence. If a woman is concerned about not having easy access to a bathroom during physical activity, she can walk indoors, like in a mall, for example. Women who are overweight should talk with their health care professional about strategies for losing weight. Being obese increases a person’s chances of developing urinary incontinence and other diseases, such as diabetes. According to one study, decreasing obesity and diabetes may lessen the burden of urinary incontinence, especially in women 6.

Gastrointestinal (GI) problems, especially constipation, can make urinary tract health worse and can lead to urinary incontinence. The opposite is also true: Urinary problems such as urinary incontinence can make GI problems worse. For example, medications such as antimuscarinics, which health care professionals use to treat urinary incontinence, have side effects such as constipation.

Health care professionals can offer several options for treating constipation.

Although a woman may be reluctant to engage in physical activity when she has urinary incontinence, regular exercise is important for weight management and good overall health.

Stopping Smoking. People who smoke should stop. Quitting smoking at any age promotes bladder health and overall health. Smoking increases a person’s chances of developing stress incontinence, as it increases coughing. Some people say smoking worsens their bladder irritation. Smoking causes most cases of bladder cancer. People who smoke for many years have a higher risk of bladder cancer than nonsmokers or those who smoke for a short time 7.

Bladder training. Bladder training is changing urination habits to decrease incidents of urinary incontinence. Based on a woman’s bladder diary, the health care professional may suggest using the bathroom at regular timed intervals, called timed voiding. Gradually lengthening the time between trips to the bathroom can help by stretching the bladder so it can hold more urine. Recording daily bathroom habits may be helpful.

Pelvic floor muscle exercises. Pelvic floor muscle, or Kegel, exercises involve strengthening pelvic floor muscles. Strong pelvic floor muscles more effectively hold in urine than weak muscles. A woman does not need special equipment for Kegel exercises. The exercises involve tightening and relaxing the muscles that control urine flow. Pelvic floor exercises should not be performed during urination. A health care professional can help a woman learn proper technique.

Women may also learn how to perform Kegel exercises properly by using biofeedback. Biofeedback uses special sensors to measure bodily functions, such as muscle contractions that control urination. A video screen displays the measurements as graphs, and sounds indicate when the woman is using the correct muscles. The health care professional uses the information to help the woman change abnormal function of the pelvic floor muscles. At home, the woman practices to improve muscle function. The woman can perform the exercises while lying down, sitting at a desk, or standing up. Success with pelvic floor exercises depends on the cause of urinary incontinence, its severity, and the woman’s ability to perform the exercises on a regular basis.

If behavioral and lifestyle changes, stopping smoking, bladder training, and pelvic floor muscle exercises are not successful, additional measures for stress incontinence, including medical devices, bulking agents, and—as a last resort—surgery, may help.

Medical devices. A health care professional may prescribe a urethral insert or pessary to treat stress incontinence. A urethral insert is a small, tamponlike, disposable device inserted into the urethra to prevent leakage. A woman may use the insert to prevent urinary incontinence during a specific activity or wear it throughout the day. The woman removes the insert to urinate. A pessary is a stiff ring inserted into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pressure helps reposition the urethra, leading to less leakage. The woman should remove the pessary regularly for cleaning.

Bulking agents. A doctor injects bulking agents, such as collagen and carbon beads, near the urinary sphincter to treat urgency and stress incontinence. The bulking agent makes the tissues thicker and helps close the bladder opening. Before the procedure, a health care professional may perform a skin test to make sure the woman doesn’t have an allergic reaction to the bulking agent. A doctor performs the procedure during an office visit. The woman receives local anesthesia. The doctor uses a cystoscope—a tubelike instrument used to look inside the urethra and bladder—to guide the needle for injection of the bulking agent. Over time, the body may slowly eliminate certain bulking agents, so a woman may need to have injections again. The treatment is effective in about 40 percent of cases 8.

Surgery. The bladder neck dropping toward the vagina can cause incontinence problems. Surgery to treat stress incontinence includes retropubic suspension and sling procedures. A doctor performs the operations in a hospital. The patient receives general anesthesia. Most women can leave the hospital the same day, though some may need to stay overnight. Full recovery takes 2 to 3 weeks; women who also have surgery for pelvic organ prolapse at the same time may have a longer recovery time.

Retropubic suspension. With retropubic suspension, the doctor raises the bladder neck or urethra and supports it using surgical threads called sutures. The doctor makes an incision in the area between the chest and the hips—also called the abdomen—a few inches below the navel and secures the sutures to strong ligaments within the pelvis to support the urethral sphincter.

Sling. The doctor performs sling procedures through a vaginal incision and uses natural tissue, man-made sling material, or synthetic mesh tape to cradle the bladder neck or urethra, depending on the type of sling procedure being performed. The doctor attaches the sling to the pubic bone or pulls the sling through an incision behind the pubic bone or beside the vaginal opening and secures it with stitches.

The Urinary Incontinence Treatment Network compared the suspension and sling procedures and found that according to women’s bladder diaries, about 31 percent with a sling and 24 percent with a suspension were still continent, or able to hold urine, all of the time 5 years after surgery. However, 73 percent of women in the suspension group and 83 percent of women in the sling group said they were satisfied with their results. Rates of adverse events such as urinary tract infections and urinary incontinence were similar for the two groups, at 10 percent for the suspension group and 9 percent for the sling group 9.

Serious complications are associated with the use of surgical mesh to repair incontinence. Possible complications include erosion through the lining of the vagina, infection, pain, urinary problems, and recurrence of incontinence.

Each woman should speak to her health care professional to help decide which surgery, if any, is right for her.

Urgency Incontinence

Women who have urgency incontinence can use the same techniques as for stress incontinence, including bladder training, urgency suppression, pelvic floor exercises, and behavioral and lifestyle changes. A woman can also try urgency suppression techniques, medications, Botox injections, and electrical nerve stimulation if necessary.

Urgency suppression. By using certain techniques, a woman can suppress the strong urge to urinate, called urgency suppression. Urgency suppression is a way to train the bladder to maintain control so a woman does not have to panic about finding a bathroom in the meantime. Some women use distraction techniques to take their mind off the urge to urinate. Other women find taking long, relaxing breaths and being still can help. Doing pelvic floor exercises also can help suppress the urgency to urinate.

Medications. Health care professionals may prescribe medications that relax the bladder or decrease bladder spasms to treat urgency incontinence in women.

Antimuscarinics. Antimuscarinics can help relax bladder muscles and prevent bladder spasms. These medications include oxybutynin (Oxytrol), which a person can buy over the counter, tolterodine (Detrol), darifenacin (Enablex), trospium (Sanctura), fesoterodine (Toviaz), and solifenacin (VESIcare). They are available in pill, liquid, and patch form.

Tricyclic antidepressants. Tricyclic antidepressants such as imipramine (Tofranil) can calm nerve signals, decreasing spasms in bladder muscles.

Beta-3 agonists. Mirabegron (Myrbetriq) is a beta-3 agonist a person takes by mouth to help prevent symptoms of incontinence. Mirabegron suppresses involuntary bladder contractions.

Botox. A doctor may use onabotulinumtoxinA (Botox), also called botulinum toxin type A, to treat urgency incontinence in women including those with neurological conditions such as spinal cord injury or multiple sclerosis. Injecting Botox into the bladder relaxes the bladder, increasing storage capacity and decreasing urinary incontinence. A doctor often performs the procedure during an office visit. A woman receives local anesthesia. The doctor uses a cystoscope to guide the needle for injecting the Botox. Botox is effective for up to 10 months.

Electrical nerve stimulation. If behavioral and lifestyle changes and medications do not improve symptoms, the health care professional may suggest electrical nerve stimulation as an option to prevent urinary incontinence, urinary frequency—urinating more than normal—and other symptoms. Electrical nerve stimulation involves altering bladder reflexes using pulses of electricity. The two most common types of electrical nerve stimulation are percutaneous tibial nerve stimulation and sacral nerve stimulation 4.

Percutaneous tibial nerve stimulation uses electrical stimulation of the tibial nerve, which is located in the ankle, on a weekly basis. Anesthesia is not normally needed for the procedure. In an outpatient center, a health care professional inserts a battery-operated stimulator beneath the skin near the tibial nerve. Electrical stimulation of the tibial nerve prevents bladder activity by interfering with the pathway between the bladder and the spinal cord or brain. Although percutaneous tibial nerve stimulation is considered safe, researchers continue to study the exact ways it prevents symptoms and how long the treatment can last.

Sacral nerve stimulation involves a health care professional implanting a battery-operated stimulator beneath the skin in the lower back near the sacral nerve. The procedure takes place in an outpatient center often with local anesthesia. Based on the person’s feedback, the health care professional can adjust the amount of stimulation so it works best for that individual. The electrical pulses enter the body for minutes to hours, two or more times a day, either through wires placed on the lower back or just above the pubic area—between the navel and the pubic hair—or through special devices inserted into the vagina. Sacral nerve stimulation may increase blood flow to the bladder, strengthen pelvic muscles that help control the bladder, and trigger the release of natural substances that block pain. The person can turn the stimulator on or off at any time. If a period of test stimulation is successful, a health care professional will implant a device that delivers regular impulses to the bladder. A health care professional places a wire next to the tailbone and attaches it to a permanent stimulator under the skin of the lower abdomen.

If behavioral and lifestyle changes and medications do not improve symptoms, the health care professional may suggest electrical nerve stimulation as an option to prevent urinary incontinence, urinary frequency, and other symptoms.

Mixed Incontinence

Depending on the type of symptoms a woman has, she may successfully treat her mixed incontinence with techniques, medications, devices, or surgery. A health care professional can help decide what kind of treatments may work for each symptom.

Functional Incontinence

Women with functional incontinence may wear protective undergarments if they worry about reaching a toilet in time. Women who have functional incontinence should talk to their health care professional about its causes and how to prevent or treat functional incontinence.

Overflow Incontinence

A health care professional treats overflow incontinence caused by a blockage in the urinary tract with surgery to remove the obstruction. Women with overflow incontinence that is not caused by a blockage may need to use a catheter to empty the bladder. A catheter is a thin, flexible tube that is inserted through the urethra into the bladder to drain urine. A health care professional can teach a woman how to use a catheter. A woman may need to use a catheter once in a while, a few times a day, or all the time. Catheters that are used continuously drain urine from the bladder into a bag that is attached to the woman’s thigh with a strap. Women using a continuous, often called indwelling, catheter should watch for symptoms of a urinary tract infection.

Transient Incontinence

A health care professional treats transient incontinence by addressing the underlying cause. For example, if a medication is causing increased urine production leading to urinary incontinence, a health care professional may try lowering the dose or prescribing a different medication. A health care professional may prescribe bacteria-fighting medications called antibiotics to treat urinary tract infections.

How can someone cope with leaking urine ?

Even after treatment, some women still leak urine from time to time. Certain products can help women cope with leaking urine:

  • Pads. Women can wear disposable pads in their underwear to absorb leaking urine.
  • Adult diapers. A woman can wear an adult diaper to keep her clothes dry.
  • Waterproof underwear. Waterproof underwear can protect clothes from getting wet.
  • Disposable pads. Disposable pads can be used to protect chairs and beds from urine.
  • Special skin cleaners and creams. Special skin cleaners and creams may help the skin around the urethra from becoming irritated. Creams can help block urine from skin.
  • Urine deodorizing tablets. A woman should talk with a health care professional about whether urine deodorizing tablets can make her urine smell less strongly.

Eating, Diet, and Nutrition

No direct scientific evidence links eating, diet, and nutrition to either improving or worsening urinary incontinence. However, many people find that alcohol, tomatoes, spices, chocolate, caffeinated and citrus beverages, and high-acid foods may contribute to bladder irritation and inflammation, which can sometimes lead to urinary incontinence 10. Moreover, good eating, diet, and nutrition are directly related to preventing factors that increase the chances of developing urinary incontinence, such as obesity and diabetes.

  1. Bladder Control Problems in Men (Urinary Incontinence). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-men[]
  2. Buckley BS, Lapitan MCM. Prevalence of urinary incontinence in men, women, and children—current evidence: findings of the Fourth International Consultation on Incontinence. Urology. 2010;76(2):265–270.[][]
  3. National Cancer Institute. What You Need to Know About Bladder Cancer. Rockville, MD; 2010. Booklet.[]
  4. Staskin DR, Peters KM, MacDiarmid S, Shore N, de Groat WC. Percutaneous tibial nerve stimulation: a clinically and cost effective addition to the overactive bladder algorithm of care. Current Urology Reports. 2012;13(5):327–334.[][]
  5. Bladder Control Problems in Women (Urinary Incontinence). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-women[]
  6. Markland AD, Richter HE, Fwu CW, Eggers P, Kusek JW. Prevalence and trends of urinary incontinence in adults in the United States, 2001 to 2008. Journal of Urology. 2011;186(2):589–593.[]
  7. National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services. What You Need to Know About Bladder Cancer. Rockville, MD: National Cancer Institute; 2010. NIH Publication No.10-1559.[]
  8. Deng DY. Urinary incontinence in women. Medical Clinics of North America. 2011;95(1):101–109.[]
  9. Brubaker L, Richter HE, Norton PA, et al. 5-year continence rates, satisfaction and adverse events of Burch urethropexy and fascial sling surgery for urinary incontinence. Journal of Urology. 2012;187(4):1324–1330.[]
  10. Friedlander JI, Shorter B, Moldwin RM. Diet and its role in interstitial cystitis/bladder pain syndrome (IC/BPS) and comorbid conditions. BJU International. 2012;109(11):1584–1591.[]
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Conditions & DiseasesKidneysUrinary System

Kidney failure

kidney failure

What is kidney failure

Kidney failure means your kidneys no longer work well enough to do their job 1. 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.

Glomerular filtration rate (GFR) is the best measure of overall kidney function in health and disease 2. The normal level of glomerular filtration rate (GFR) varies according to age, sex, and body size. Normal glomerular filtration rate (GFR) in young adults is approximately 120 to 130 mL/min per 1.73 m² and declines with age 3. A glomerular filtration rate (GFR) level less than 60 mL/min per 1.73 m² represents loss of half or more of the adult level of normal kidney function. Below this level, the prevalence of complications of chronic kidney disease increases. Although the age-related decline in GFR has been considered part of normal aging, decreased GFR in the elderly is an independent predictor of adverse outcomes, such as death and cardiovascular disease 4. In addition, decreased GFR in the elderly requires adjustment in drug dosages, as in other patients with chronic kidney disease 5. Therefore, the definition of chronic kidney disease is the same, regardless of age. Because GFR declines with age, the prevalence of chronic kidney disease increases with age; approximately 17% of persons older than 60 years of age have an estimated GFR less than 60 mL/min per 1.73 m² 6.

The National Kidney Foundation Practice Guidelines define kidney failure as either:

  1. GFR less than 15 mL/min per 1.73 m², which is accompanied in most cases by signs and symptoms of uremia, or
  2. A need to start kidney replacement therapy (dialysis or transplantation).

Having kidney failure means that:

  • 85-90% of your kidney function is gone
  • your kidneys don’t work well enough to keep you alive

There is no cure for kidney failure, but with treatment it is possible to live a long life.

  • Approximately 98% of patients with kidney failure in the United States begin dialysis when their GFR is less than 15 mL/min per 1.73 m² 7. Kidney failure is not synonymous with end-stage renal disease (ESRD). End-stage renal disease is an administrative term in the United States. It indicates that a patient is treated with dialysis or transplantation, which is the condition for payment for health care by the Medicare end-stage renal disease Program. The classification of end-stage renal disease does not include patients with kidney failure who are not treated with dialysis and transplantation. Thus, although the term end-stage renal disease provides a simple operational classification of patients according to treatment, it does not precisely define a specific level of kidney function.
  • The level of kidney function, regardless of diagnosis, determines the stage of chronic kidney disease according to the Kidney Disease Outcomes Quality Initiative chronic kidney disease classification.

Every day, your kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2 quarts of urine, composed of wastes and extra fluid. Kidney failure means your kidneys are not filtering as well as they should. When your kidneys fail, harmful wastes and extra salt and fluid buildup in your body. You then need treatment to replace the work your damaged kidneys have stopped doing.

Your kidneys filter wastes and extra fluid from your blood to keep you healthy. The wastes and extra fluid become urine that is stored in your bladder until you urinate. When your kidneys fail, dialysis can take over a small part of the work your damaged kidneys can no longer do.

The treatments for kidney failure are:

  • Hemodialysis
  • Peritoneal dialysis
  • Kidney transplant

These treatments can help you stay well.

Left untreated, kidney failure will lead to coma, seizures, and death.

You can make treatments work better by:

  • sticking to your treatment schedule
  • taking all medicines your doctor prescribes
  • following a special diet that keeps wastes from building up in your blood
  • being active most days of the week.

What causes kidney failure

Kidneys can become damaged from a physical injury or a disease like diabetes, high blood pressure, or other disorders.

Diabetes is the most common cause of kidney failure. High blood pressure is the second most common cause of kidney failure.

Other problems that can cause kidney failure include 8:

  • Autoimmune diseases, such as lupus and IgA nephropathy
  • Genetic diseases (diseases you are born with), such as polycystic kidney disease
  • Nephrotic syndrome
  • Urinary tract problems

Sometimes the kidneys can stop working very suddenly (within two days). This type of kidney failure is called acute kidney injury or acute renal failure. Common causes of acute renal failure include:

  • Heart attack
  • Illegal drug use and drug abuse
  • Not enough blood flowing to the kidneys
  • Urinary tract problems

This type of kidney failure is not always permanent. Your kidneys may go back to normal or almost normal with treatment and if you do not have other serious health problems.

Having one of the health problems that can lead to kidney failure does not mean that you will definitely have kidney failure.

Kidney failure does not happen overnight. It is the end result of a gradual loss of kidney function. In fact, some people do not even know they have kidney disease until their kidneys fail. Why not? Because people with early kidney disease may not have any symptoms. Symptoms usually show up late in the progression of the disease.

What are signs and symptoms of kidney failure

Healthy kidneys remove wastes and extra fluid from your blood. But when your kidneys fail, wastes and extra fluid can build up in your blood and make you feel sick. You may have some of the following symptoms:

  • nausea
  • little or no urination
  • headaches
  • drowsiness
  • trouble sleeping
  • loss of appetite
  • weight loss
  • weakness
  • fatigue, or feeling tired
  • generalized itching or numbness
  • weight loss
  • muscle cramps (especially in the legs)
  • high blood pressure
  • edema—swelling, usually in the legs, feet, or ankles and less often in the hands or face
  • anemia (a low blood count)
  • trouble sleeping
  • darkened skin
  • dry skin
  • trouble concentrating
  • vomiting

When these conditions occur, you need treatment to replace the work your damaged kidneys have stopped doing. Left untreated, kidney failure will lead to coma, seizures, and death.

Once you begin treatment for kidney failure, your symptoms will improve and you will begin to feel much better.

Stages of kidney failure

Chronic kidney disease progresses in stages.

The Glomerular filtration rate (GFR) provides an estimate of how much blood is filtered by the kidneys each minute. In normal kidneys GFR > 60 ml/minute. A GFR of less than 60 ml/minute/1.73m² may mean you have kidney disease

Table 1. Reference Table for Population Mean eGFR from NHANES III

Age (years)Mean eGFR (mL/min/1.73 m²)
20–29116
30–39107
40–4999
50–5993
60–6985
7075
[Source 9]

Each chronic kidney disease patient is classified into one of the following 5 stages of CKD based on their estimated glomerular filtration rate (eGFR) and the level of proteinuria, because management and prognosis varies according to the progression of damage.

  • CKD Stage 1: Kidney damage with normal or increased eGFR (above 90 mL/min/1.73 m²), but other tests have detected signs of kidney damage
  • CKD Stage 2: Mild reduction in eGFR (60-89 mL/min/1.73 m²), with other signs of kidney damage
  • CKD Stage 3: Moderate reduction in eGFR (30-59 mL/min/1.73 m²)
    • Stage 3a (G3a) – an eGFR of 45 to 59ml/min/1.73 m²
    • Stage 3b (G3b) – an eGFR of 30 to 44ml/min/1.73 m²
  • CKD Stage 4: Severe reduction in eGFR (15-29 mL/min/1.73 m²)
  • CKD Stage 5 (End Stage Kidney Disease or ESRD): Kidney failure (eGFR less than 15 mL/min/1.73 m²), meaning the kidneys have lost almost all of their function and require dialysis

Alongside your eGFR, your urine albumin:creatinine ratio (ACR) can help give a more accurate picture of how well your kidneys are working.

Your albumin:creatinine ratio (ACR) result is given as a stage from 1 to 3:

  • A1 – an ACR of less than 3mg/mmol
  • A2 – an ACR of 3 to 30mg/mmol
  • A3 – an ACR of more than 30mg/mmol

For both eGFR and ACR, a higher stage indicates more severe kidney disease.

Stages-of-Chronic-Kidney-Disease

How will kidney failure affect your life?

Kidney failure will affect your life in many ways. You may find you cannot do all the things you used to do at home or at work. You may have less energy and may feel depressed. Physical problems may include:

  • ankle or belly swelling
  • stomach sickness
  • throwing up
  • loss of appetite
  • feeling tired
  • weakness
  • confusion
  • headaches

Having kidney failure does not have to take over your life. Having kidney failure does not have to mean giving up hobbies, work, social activities, or time with family.

Can you continue to work with kidney failure?

Yes, many people with kidney failure continue to work. Your employer may give you lighter physical jobs or schedule your work hours around your hemodialysis sessions. If you are on peritoneal dialysis, you will need space and time to change the dialysis solution in the middle of the work day. Most employers are happy to make these changes.

As a result of the Americans with Disabilities Act, an employer cannot fire you because you are on dialysis or had a kidney transplant. The law requires an employer to make reasonable adjustments to the workplace for a person with a disability. If your employer is not willing to meet your needs, your dialysis clinic’s renal social worker may be able to help find a way to satisfy both you and your employer. As a last resort, you may need to file a complaint with the Equal Employment Opportunity Commission. Your renal social worker may be able to help you with this complaint, or you may need the help of a lawyer. Many times, just the mention of legal action is enough to cause an employer to make reasonable changes in the workplace.

Can you be active with kidney failure?

Yes. Physical activity is an important part of staying healthy when you have kidney failure. Being active makes your muscles, bones, and heart stronger. Physical activity also makes your blood circulate faster so your body gets more oxygen. Your body needs oxygen to use the energy from food. If you are on dialysis, physical activity can help more wastes move into your blood for dialysis to remove them.

You will find that physical activity can also improve your mood and give you a sense of well-being.

Talk with your doctor before you start an exercise routine. Start slow, with easier activities such as walking at a normal pace or gardening. Work up to harder activities such as walking briskly or swimming. Aim for at least 30 minutes of exercise most days of the week.

Kidney failure treatment

You have three treatment options to choose from to filter your blood. A fourth option offers care without replacing the work of the kidneys. None of these treatments helps the kidneys get better. However, they all can help you feel better.

  1. Hemodialysis uses a machine to move your blood through a filter outside your body, removing wastes.
  2. Peritoneal dialysis uses the lining of your belly to filter your blood inside your body, removing wastes.
  3. Kidney transplantation is surgery to place a healthy kidney from a person who has just died or a living person, usually a family member, into your body to take over the job of filtering your blood.
  4. Conservative management is the choice not to treat kidney failure with dialysis or a transplant. Instead, the focus is on using medicines to keep you comfortable, preserving kidney function through diet, and treating the problems of kidney failure, such as anemia—a shortage of red blood cells that can make you tired—and weak bones.

How does Hemodialysis work?

Purpose of Hemodialysis

The purpose of hemodialysis is to filter your blood. This type of dialysis uses a machine to remove harmful wastes and extra fluid, as your kidneys did when they were healthy. Hemodialysis helps control blood pressure and balance important minerals, such as potassium, sodium, calcium, and bicarbonate, in your blood. Hemodialysis is not a cure for kidney failure; however, it can help you feel better and live longer.

How Hemodialysis Works

Before you can begin dialysis, a surgeon will create a vascular access, usually in your arm. A vascular access lets high volumes of blood flow continuously during hemodialysis treatments to filter the largest possible amounts of blood per treatment.

Hemodialysis uses a machine to move your blood through a filter, called a dialyzer, outside your body. A pump on the hemodialysis machine draws your blood through a needle into a tube, a few ounces at a time. Your blood then travels through the tube, which takes it to the dialyzer. Inside the dialyzer, your blood flows through thin fibers that filter out wastes and extra fluid. After the dialyzer filters your blood, another tube carries your blood back to your body. You can do hemodialysis at a dialysis center or in your home.

Hemodialysis can replace part of your kidney function. You will also need dietary changes, medicines, and limits on water and other liquids you drink and get from food. Your dietary changes, the number of medicines you need, and limits on liquid will depend on where you receive your treatments—at a dialysis center or at home—and how often you receive treatments—three or more times a week.

Pros and Cons of Hemodialysis

The pros and cons of hemodialysis differ for each person. What may be bad for one person may be good for another. Following is a list of the general pros and cons of dialysis center and home hemodialysis.

Dialysis Center Hemodialysis

Pros

  • Dialysis centers are widely available.
  • Trained health care providers are with you at all times and help administer the treatment.
  • You can get to know other people with kidney failure who also need hemodialysis.
  • You don’t have to have a trained partner or keep equipment in your home.

Cons

  • The center arranges everyone’s treatments and allows few exceptions to the schedule.
  • You need to travel to the center for treatment.
  • This treatment has the strictest diet and limits on liquids because the longer time between treatments means wastes and extra fluid can build up in your body.
  • You may have more frequent ups and downs in how you feel from day to day because of the longer time between sessions.
  • Feeling better after a treatment may take a few hours.
Home Hemodialysis

Pros

  • You can do the treatment at the times you choose; however, you should follow your doctor’s orders about how many times a week you need treatment.
  • You don’t have to travel to a dialysis center.
  • You gain a sense of control over your treatment.
  • You will have fewer ups and downs in how you feel from day to day because of more frequent sessions.
  • You can do your treatments at times that will let you work outside the home.
  • You will have a more manageable diet and fewer limits on liquids because the shorter time between sessions prevents the buildup of wastes and extra fluid.
  • You can take along a hemodialysis machine when traveling.
  • You can spend more time with your loved ones because you don’t have to go to the dialysis center three times a week.

Cons

  • Not all dialysis centers offer home hemodialysis training and support.
  • You and a family member or friend will have to set aside a week or more at the beginning for training.
  • Helping with treatments may be stressful for your family or friend.
  • You need space for storing the hemodialysis machine and supplies at home.
  • You will need to learn to put dialysis needles into your vascular access.
  • Medicare and private insurance companies may limit the number of treatments they will pay for when you use home hemodialysis. Few people can afford the costs for additional treatments.

Figure 1. Hemodialysis

hemodialysis for kidney failure

hemodialysis unit for kidney failure

How does Peritoneal Dialysis work ?

Purpose of Peritoneal Dialysis

The purpose of peritoneal dialysis is to filter wastes and extra fluid from your body. This type of dialysis uses the lining of your belly—the space in your body that holds your stomach, bowels, and liver—to filter your blood. This lining, called the peritoneum, acts to do the work of your kidneys.

How Peritoneal Dialysis Works

A doctor will place a soft tube, called a catheter, in your belly a few weeks before you start treatment. The catheter stays in your belly permanently. When you start peritoneal dialysis, you will empty a kind of salty water, called dialysis solution, from a plastic bag through the catheter into your belly. When the bag is empty, you can disconnect your catheter from the bag so you can move around and do your normal activities. While the dialysis solution is inside your belly, it soaks up wastes and extra fluid from your body. After a few hours, you drain the used dialysis solution through another tube into a drain bag. You can throw away the used dialysis solution, now filled with wastes and extra fluid, in a toilet or tub. Then you start over with a fresh bag of dialysis solution. The process of emptying the used dialysis solution and refilling your belly with fresh solution is called an exchange. The process goes on continuously, so you always have dialysis solution in your belly soaking up wastes and extra fluid from your body.

Figure 2. Peritoneal dialysis

peritoneal dialysis for kidney failure

Types of Peritoneal Dialysis

Two types of peritoneal dialysis are available. After you have learned about the types of peritoneal dialysis, you can choose the type that best fits your life. If one schedule or type of peritoneal dialysis does not suit you, talk with your doctor about trying the other type.

Continuous ambulatory peritoneal dialysis does not require a machine and you can do it in any clean, well-lit place. The time period that the dialysis solution is in your belly is the dwell time. With continuous ambulatory peritoneal dialysis, the dialysis solution stays in your belly for a dwell time of 4 to 6 hours, or more. The process of draining the used dialysis solution and replacing it with fresh solution takes about 30 to 40 minutes. Most people change the dialysis solution at least four times a day and sleep with solution in their belly at night. With continuous ambulatory peritoneal dialysis, you do not have to wake up and perform dialysis tasks during the night.

Continuous cycler-assisted peritoneal dialysis uses a machine called a cycler to fill and empty your belly three to five times during the night while you sleep. In the morning, you begin one exchange with a dwell time that lasts the entire day. You may do an additional exchange in the middle of the afternoon without the cycler to increase the amount of waste removed and to reduce the amount of fluid left behind in your body.

You may need a combination of continuous ambulatory peritoneal dialysis and continuous cycler-assisted peritoneal dialysis if you weigh more than 175 pounds or if your peritoneum filters wastes slowly. For example, some people use a cycler at night and perform one exchange during the day. Others do four exchanges during the day and use a minicycler to perform one or more exchanges during the night. You’ll work with your health care team to find the best schedule for you.

Pros and Cons of Peritoneal Dialysis

Each type of peritoneal dialysis has pros and cons.

Continuous Ambulatory Peritoneal Dialysis

Pros

  • You can do continuous ambulatory peritoneal dialysis alone.
  • You can do continuous ambulatory peritoneal dialysis at the times you choose, as long as you perform the required number of exchanges each day.
  • You can do continuous ambulatory peritoneal dialysis in many locations.
  • You can travel as long as you bring dialysis bags with you or have them delivered to your destination.
  • You don’t need a machine for continuous ambulatory peritoneal dialysis.
  • You gain a sense of control over your treatment.

Cons

  • Continuous ambulatory peritoneal dialysis can disrupt your daily schedule.
  • Continuous ambulatory peritoneal dialysis is a continuous treatment, and you should do all exchanges 7 days a week.
  • Boxes of dialysis solution will take up space in your home.

Continuous Cycler-assisted Peritoneal Dialysis

Pros

  • You can do exchanges at night, while you sleep.
  • You may not have to perform exchanges during the day.

Cons

  • You need a machine.
  • Your connection to the cycler limits your movement at night.

Is dialysis a cure for kidney failure ?

No. Hemodialysis and peritoneal dialysis help you feel better and live longer; however, they do not cure kidney failure. Although people with kidney failure are now living longer than ever, over the years kidney disease can cause other problems, such as heart disease, bone disease, arthritis, nerve damage, infertility, and malnutrition. These problems won’t go away with dialysis; however, doctors now have new and better ways to prevent or treat them. You should discuss these problems and their treatments with your doctor.

How Kidney Transplantation Works

The transplant process has many steps.

The first step is to talk with your health care provider about whether you are a candidate for a transplant. Transplantation is not for everyone. Your health care provider may tell you that you are not healthy enough for surgery or that you have a condition that would make transplantation unlikely to succeed. If you are a good candidate for a transplant, your health care provider will refer you to a transplant center.

Medical, Psychological, and Social Evaluation at a Transplant Center

The next step is a thorough physical, psychological, and social evaluation at the transplant center, where you will meet members of your transplant team. Your pretransplant evaluation may require several visits to the transplant center over the course of weeks or even months.

You will need to have blood tests as well as other tests to check your heart and other organs. Your blood type and other matching factors help determine whether your body will accept an available donor kidney.

Your transplant team will make sure you are healthy enough for surgery. Some medical conditions or illnesses could make transplantation less likely to succeed.

In addition, your team will make sure you can understand and follow the schedule for taking the medicines needed after surgery. Team members need to be sure that you are mentally prepared for the responsibilities of caring for a transplanted kidney.

If a family member or friend wants to donate a kidney, that person will need a health exam to test whether the kidney is a good match.

Who is on your transplant team ?

Your transplant team has many members, including your

  • surgeon—the doctor who places the kidney in your body.
  • nephrologist—a doctor who specializes in kidney health. The nephrologist may work in partnership with a nurse practitioner or a physician’s assistant.
  • transplant coordinator—a specially trained nurse who will be your point of contact, arrange your appointments, and educate you before and after the transplant.
  • social worker—a person who is trained to help people solve problems in their daily lives, such as finding employment, affordable housing, or daycare.
  • dietitian—a person who is an expert in food and nutrition. Dietitians teach people about the foods they should eat and how to plan healthy meals.

Placement on the Waiting List

If your medical evaluation shows you are a good candidate for a transplant, your transplant center will submit your name to be placed on the national waiting list for a kidney from a deceased donor. The Organ Procurement and Transplantation Network has a computer network that links all regional organ-gathering organizations—known as organ procurement organizations—and transplant centers. The United Network for Organ Sharing (UNOS), a private, nonprofit organization, runs the Organ Procurement and Transplantation Network under a contract with the Federal Government. When UNOS officially adds you to the waiting list, UNOS will notify you and your transplant team.

UNOS allows you to register with multiple transplant centers to increase your chances of receiving a kidney. Each transplant center usually requires a separate medical evaluation.

Waiting Period

UNOS gives preference to people who have been on the waiting list the longest. However, other factors—such as your age, where you live, and your blood type—may make your wait longer or shorter. Wait times can range from a few months to several years.

If you have a living donor, you do not need to be placed on the waiting list and can schedule the surgery when it is convenient for you and your donor.

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

While you wait for a kidney, you will have blood drawn once a month. The sample will be sent to the transplant center. The center must have a recent sample of your blood for comparison with any kidney that becomes available.

Organ procurement organizations identify potential organs for transplant and coordinate with the national network. When a deceased donor kidney becomes available, the organ procurement organization notifies UNOS and creates a computer-generated list of suitable recipients.

Whether you are receiving your kidney from a deceased donor or a living donor, the transplant team considers three factors in matching kidneys with potential recipients. These matching factors help predict whether your body’s immune system—which protects your body from infection by identifying and destroying bacteria, viruses, and other potentially harmful foreign substances—will accept or reject the new kidney.

  • Blood type. Your blood type—A, B, AB, or O—must be compatible with the donor’s. Blood type is the most important matching factor. Some transplant centers have developed techniques for transplanting kidneys that are not matched by blood type.
  • Human leukocyte antigens. These six antigens are proteins that help your immune system tell the difference between your own body’s tissues and foreign substances. You may still receive a kidney if the antigens do not completely match, as long as your blood type is compatible with the organ donor’s blood type and other tests show no problems with matching.
  • Cross-matching antigens. The cross-match is the last test performed before a kidney transplant can take place. A lab technician mixes a small sample of your blood with a sample of the organ donor’s blood in a tube to see if the mixture causes a reaction. If no reaction occurs—called a negative cross-match—the transplant can proceed.

Kidney Transplant Surgery

If you are on a waiting list for a deceased donor kidney, you must go to the hospital as soon as you receive notification that a kidney is available. If a family member or friend is donating the kidney you will receive, you will schedule the operation in advance. Your transplant team will operate on you and your donor at the same time, usually in side-by-side rooms. One surgeon will perform the nephrectomy—the removal of the kidney from the donor—while another prepares you for placement of the donated kidney. In some centers, the same surgeon performs both operations. You will receive general anesthesia to make you sleep during the operation. The surgery usually takes 3 or 4 hours.

Surgeons—place most transplanted kidneys in the lower front part of your abdomen. The kidney is connected to an artery, which brings unfiltered blood into the kidney, and a vein, which takes filtered blood out of the kidney. The surgeon also transplants the ureter from the donor to let urine from the new kidney flow to your bladder. Unless your damaged kidneys cause problems such as infection, they can remain in their normal position. The transplanted kidney takes over the job of filtering your blood. Your body normally attacks anything it sees as foreign, so to keep your body from attacking the kidney you need to take medicines called immunosuppressants for as long as the transplanted kidney functions.

Recovery from Kidney Transplant Surgery

After surgery, you will probably feel sore and groggy when you wake up. However, many people who have a transplant report feeling much better immediately after surgery. Even if you wake up feeling great, you will typically need to stay in the hospital for several days to recover from surgery, and longer if you have any complications. You will have regular follow-up visits after leaving the hospital.

If you have a living donor, the donor will probably also stay in the hospital for several days. However, a new technique for removing a kidney for donation uses a smaller incision and may make it possible for the donor to leave the hospital in 2 to 3 days.

Pros and Cons of Kidney Transplantation

Following is a list of the pros and cons of kidney transplantation.

Kidney Transplantation

Pros

  • A transplanted kidney works like a healthy kidney.
  • If you have a living donor, you can choose the time of your operation.
  • You may feel healthier and have an improved quality of life.
  • You have fewer dietary restrictions.
  • You won’t need dialysis.
  • People who receive a donated kidney have a greater chance of living a longer life than those who stay on dialysis.

Cons

  • Transplantation requires surgery.
  • You will go through extensive medical testing at the transplant clinic.
  • You may need to wait years for a deceased donor kidney.
  • Your body may reject the new kidney, so one transplant may not last a lifetime.
  • You’ll need to take immunosuppressants, which may cause other health problems, for as long as the transplanted kidney functions.

What do you need to know about care after your kidney transplant ?

You need to know how to keep your body from rejecting your new kidney. Your immune system will sense that your new kidney is foreign. To keep your body from rejecting it, you will have to take medicines, called immunosuppressants, that turn off, or suppress, your immune system response. You may have to take two or more immunosuppressants, as well as medicines such as antibiotics to protect against infections. Your transplant team will teach you what each medicine is for and when to take each one. Be sure you understand the instructions for taking your medicines before you leave the hospital.

What are signs that your body is rejecting your new kidney ?

Often, rejection begins before any signs appear. The signs of rejection include indications that your kidney is not working as well as it should—for example, high blood pressure or swelling because your kidney is not getting rid of extra salt and fluid in your body. Advances in immunosuppressants have made other signs of rejection—such as fever, soreness in the lower abdomen where the new kidney is, and a decrease in the amount of urine you make—rare. If you have any of these symptoms, tell your transplant team. You will receive stronger doses of your immunosuppressants and additional medicines to help keep your body from rejecting your new kidney.

Even if you do everything you should, your body may still reject the new kidney, and you may need to go on dialysis. Unless your transplant team determines that you are no longer a good candidate for transplantation, you can go back on the waiting list for another kidney.

How do you know your new kidney is working properly ?

Blood tests help you know your new kidney is working. Before you leave the hospital, you will schedule an appointment with your transplant team at the transplant center. At that appointment, a health care provider will draw blood to be tested. The tests show how well your kidneys are removing wastes from your blood. At first, you may return to the transplant center every 2 weeks, then every month. Eventually, you will need to return to the transplant center only once every 6 months or once every year, after your transplant team has determined that your kidney is doing its job.

Your blood tests may show that your kidney is not removing wastes from your blood as well as it should. You may have other signs that your body is rejecting your new kidney. If these problems occur, your transplant surgeon or nephrologist may order a kidney biopsy. Biopsy is a procedure that involves taking a small piece of tissue for examination under a microscope. Your transplant surgeon or nephrologist performs the biopsy in the transplant center or a hospital. The health care provider will give you light sedation and local anesthetic; however, in some cases, a patient may require general anesthesia. A pathologist—a doctor who specializes in diagnosing diseases—examines the tissue in a lab. The test can show whether your body is rejecting your new kidney.

What are the side effects of immunosuppressants ?

Some immunosuppressants may change your appearance. Your face may get fuller; you may gain weight or develop acne or facial hair. Not all people have these problems, and those who do can use diet, makeup, and hair removal to minimize changes in appearance.

Immunosuppressants weaken your immune system, which can lead to infections. In some people over long periods of time, a weakened immune system can increase their risk of developing cancer. Some immunosuppressants cause cataracts, diabetes, extra stomach acid, high blood pressure, and bone disease. When used over time, these medicines may also cause liver or kidney damage in some people. Your transplant team will order regular tests to monitor the levels of immunosuppressants in your blood and to measure your liver and kidney function.

What financial help is available to pay for a kidney transplant ?

United States citizens who have kidney failure are eligible to receive Medicare, the Federal Government insurance program. Treatment for kidney failure costs a lot; however, Medicare pays much of the cost, usually up to 80 percent. Often, private insurance pays the rest. For people who are not eligible for Medicare or who still need help with the portion Medicare does not cover, states have Medicaid programs that provide funds for health care based on financial need. Your social worker can help you locate resources for financial help.

What help is available to pay for kidney transplant medicines ?

Through patient-assistance programs, prescription drug companies give discounts to people who can show they cannot afford the cost of their prescribed medicines. Social workers can help patients complete applications to these programs.

The Partnership for Prescription Assistance has a website that directs patients, caregivers, and doctors to more than 275 public and private patient-assistance programs, including more than 150 programs offered by pharmaceutical companies. The website www.pparx.org features tools to help a person determine which programs might be available.

NeedyMeds is a nonprofit organization that helps people find appropriate patient-assistance programs. The NeedyMeds website—www.needymeds.org —provides a directory of patient-assistance programs that can be searched by a medicine’s brand or generic name or by a program or company name. Applications for these programs are usually available online.

Eating, Diet, and Nutrition for Kidney Transplant Patients

The diet for transplant patients has more choices than the diet for dialysis patients, although you may still have to cut back on some foods. Your diet will probably change as your medicines, test results, weight, and blood pressure change.

  • You may need to count calories. Your medicines may give you a bigger appetite and cause you to gain weight.
  • You may have to eat less sodium. Your medicines may cause your body to retain sodium, leading to high blood pressure.

Your transplant center’s dietitian can help you understand the reasons for dietary limits, recognize foods you should avoid, and plan healthy and tasty meals.

What is conservative management for kidney failure ?

Conservative management for kidney failure is the choice to say no to or stop dialysis treatments. For many people, dialysis not only extends life, it also improves the quality of life. For others who have serious conditions in addition to kidney failure, dialysis may seem like a burden that only prolongs suffering. If you have serious conditions in addition to kidney failure, dialysis may not prolong your life or improve the quality of your life.

You have the right to say no to or stop dialysis. You may want to speak with your doctor, spouse, family, counselor, or renal social worker, who helps people with kidney disease, to help you make this decision.

If you stop dialysis treatments or say you do not want to begin them, you may live for a few weeks or for several months, depending on your health and your remaining kidney function. You may choose to receive care from a hospice—a facility or home program designed to meet the physical and emotional needs of the terminally ill—during this time. Hospice care focuses on relief of pain and other symptoms. Whether or not you choose to use a hospice, your doctor can give you medicines to make you more comfortable. Your doctor can also give you medicines to treat the problems of kidney failure, such as anemia or weak bones. You may restart dialysis treatment if you change your mind.

Advance Directives

An advance directive is a statement or document in which you give instructions either to withhold certain treatments, such as dialysis, or to provide them, depending on your wishes and the specific circumstances. Even if you are happy with your quality of life on dialysis, you should think about circumstances that might make you want to stop dialysis treatments. At some point in a medical crisis, you might lose the ability to tell your health care team and loved ones what you want. Advance directives may include

  • a living will
  • a durable power of attorney for health care decisions
  • a do not resuscitate (DNR) order—a legal form that tells your health care team you do not want cardiopulmonary resuscitation (CPR) or other life-sustaining treatment if your heart were to stop or if you were to stop breathing.

A living will is a document that details the conditions under which you would want to refuse treatment. You may state that you want your health care team to use all available means to sustain your life, or you may direct that you be withdrawn from dialysis if you fall into a coma from which you most likely won’t wake up. In addition to dialysis, you may choose or refuse the following life-sustaining treatments:

  • CPR
  • feedings through a tube in your stomach
  • mechanical or artificial means to help you breathe
  • medicines to treat infections
  • surgery
  • receiving blood

Refusing to have CPR is the same as a do not resuscitate (DNR) order. If you choose to have a do not resuscitate (DNR) order, your doctor will place the order in your medical chart.

A durable power of attorney for health care decisions or a health care proxy is a document you use to assign a person to make health care decisions for you in the event you cannot make them for yourself. Make sure the person you name understands your values and will follow your instructions.

Each state has its own laws on advance directives. You can obtain a form for an advance medical directive that’s valid in your state from the National Hospice and Palliative Care Organization.

Kidney failure diet

Your dialysis center has a renal dietitian to help you plan your meals. A renal dietitian has special training in caring for the food and nutrition needs of people with kidney disease. Work with a registered dietitian to develop a meal plan that includes foods that you enjoy eating while maintaining your kidney health.

Use this information to help you learn how to eat right to feel right on hemodialysis. Read one section at a time. Then, review with your renal dietitian the sections marked “Talk with Your Renal Dietitian.”

Keep a copy of this information handy to remind yourself of foods you can eat and foods to avoid.

You will need to carefully plan your meals and keep track of the amount of liquids you eat and drink. It helps to limit or avoid foods and beverages that have lots of

  • potassium
  • phosphorus
  • sodium—for example, vegetable juice and sports drinks

The first steps to eating right 10.

Step 1: Choose and prepare foods with less salt and sodium

Why? To help control your blood pressure. Your diet should contain less than 2,300 milligrams of sodium each day 10.

  • Buy fresh food often. Sodium (a part of salt) is added to many prepared or packaged foods you buy at the supermarket or at restaurants.
  • Cook foods from scratch instead of eating prepared foods, “fast” foods, frozen dinners, and canned foods that are higher in sodium. When you prepare your own food, you control what goes into it.
  • Use spices, herbs, and sodium-free seasonings in place of salt.
  • Check for sodium on the Nutrition Facts label of food packages. A Daily Value of 20 percent or more means the food is high in sodium.
  • Try lower-sodium versions of frozen dinners and other convenience foods.
  • Rinse canned vegetables, beans, meats, and fish with water before eating.

Look for food labels with words like sodium free or salt free; or low, reduced, or no salt or sodium; or unsalted or lightly salted.

Why is knowing about sodium important for someone with advanced chronic kidney disease ?

Too much sodium in a person’s diet can be harmful because it causes blood to hold fluid. People with chronic kidney disease need to be careful not to let too much fluid build up in their bodies. The extra fluid raises blood pressure and puts a strain on the heart and kidneys. A dietitian can help people find ways to reduce the amount of sodium in their diet. Nutrition labels provide information about the sodium content in food. The U.S. Food and Drug Administration advises that healthy people should limit their daily sodium intake to no more than 2,300 milligrams (mg), the amount found in 1 teaspoon of table salt. People who are at risk for a heart attack or stroke because of a condition such as high blood pressure or kidney disease should limit their daily sodium intake to no more than 1,500 mg. Choosing sodium-free or low-sodium food products will help them reach that goal.

Sodium is found in ordinary table salt and many salty seasonings such as soy sauce and teriyaki sauce. Canned foods, some frozen foods, and most processed meats have large amounts of salt. Snack foods such as chips and crackers are also high in salt.

Alternative seasonings such as lemon juice, salt-free seasoning mixes, and hot pepper sauce can help people reduce their salt intake. People with advanced chronic kidney disease should avoid salt substitutes that use potassium, such as AlsoSalt or Nu-Salt, because chronic kidney disease limits the body’s ability to eliminate potassium from the blood. The table below provides some high-sodium foods and suggestions for low-sodium alternatives that are healthier for people with any level of chronic kidney disease who have high blood pressure.

High-sodium FoodsLow-sodium Alternatives
  • Salt
  • Regular canned vegetables
  • Hot dogs and canned meat
  • Packaged rice with sauce
  • Packaged noodles with sauce
  • Frozen vegetables with sauce
  • Frozen prepared meals
  • Canned soup
  • Regular tomato sauce
  • Snack foods
  • Salt-free herb seasonings
  • Low-sodium canned foods
  • Frozen vegetables without sauce
  • Fresh, cooked meat
  • Plain rice without sauce
  • Plain noodles without sauce
  • Fresh vegetables without sauce
  • Homemade soup with fresh ingredients
  • Reduced-sodium tomato sauce
  • Unsalted pretzels
  • Unsalted popcorn

Why is knowing about potassium important for someone with advanced chronic kidney disease ?

Keeping the proper level of potassium in the blood is essential. Potassium keeps the heart beating regularly and muscles working right. Problems can occur when blood potassium levels are either too low or too high. Damaged kidneys allow potassium to build up in the blood, causing serious heart problems. Potassium is found in many fruits and vegetables, such as bananas, potatoes, avocados, and melons. People with advanced chronic kidney disease may need to avoid some fruits and vegetables. Blood tests can indicate when potassium levels have climbed above normal range. A renal dietitian can help people with advanced chronic kidney disease find ways to limit the amount of potassium they eat. The potassium content of potatoes and other vegetables can be reduced by boiling them in water. The following table gives examples of some high-potassium foods and suggestions for low-potassium alternatives for people with advanced chronic kidney disease.

High-potassium FoodsLow-potassium Alternatives
  • Oranges and orange juice
  • Melons
  • Apricots
  • Bananas
  • Potatoes
  • Tomatoes
  • Sweet potatoes
  • Cooked spinach
  • Cooked broccoli
  • Beans (baked, kidney, lima, pinto)
  • Apples and apple juice
  • Cranberries and cranberry juice
  • Canned pears
  • Strawberries, blueberries, raspberries
  • Plums
  • Pineapple
  • Cabbage
  • Boiled Cauliflower

Why is knowing about phosphorus important for someone with advanced chronic kidney disease ?

Damaged kidneys allow phosphorus, a mineral found in many foods, to build up in the blood. Too much phosphorus in the blood pulls calcium from the bones, making the bones weak and likely to break. Too much phosphorus may also make skin itch. Foods such as milk and cheese, dried beans, peas, colas, canned iced teas and lemonade, nuts, and peanut butter are high in phosphorus. A renal dietitian can help people with advanced chronic kidney disease learn how to limit phosphorus in their diet.

As chronic kidney disease progresses, a person may need to take a phosphate binder such as sevelamer hydrochloride (Renagel), lanthanum carbonate (Fosrenol), calcium acetate (PhosLo), or calcium carbonate (Tums) to control the phosphorus in the blood. These medications act like sponges to soak up, or bind, phosphorus while it is in the stomach. Because it is bound, the phosphorus does not get into the blood. Instead, it is removed from the body in the stool.

The table below lists some high-phosphorus foods and suggestions for low-phosphorus alternatives that are healthier for people with advanced chronic kidney disease.

High-phosphorus FoodsLow-phosphorus Alternatives
  • Dairy foods (milk, cheese, yogurt)
  • Beans (baked, kidney, lima, pinto)
  • Nuts and peanut butter
  • Processed meats (hot dogs, canned meat)
  • Cola
  • Canned iced teas and lemonade
  • Bran cereals
  • Egg yolks
  • Liquid non-dairy creamer
  • Sherbet
  • Cooked rice
  • Rice, wheat, and corn cereals
  • Popcorn
  • Peas
  • Lemon-lime soda
  • Root beer
  • Powdered iced tea and lemonade mixes

Step 2: Eat the right amount and the right types of protein

Why? To help protect your kidneys. When your body uses protein, it produces waste. Your kidneys remove this waste. Eating more protein than you need may make your kidneys work harder.

  • Eat small portions of protein foods.
  • Protein is found in foods from plants and animals. Most people eat both types of protein. Talk to your dietitian about how to choose the right combination of protein foods for you.

When kidney function declines to the point where dialysis becomes necessary, patients should include more protein in their diet because dialysis removes large amounts of protein from the blood.

Animal-protein foods:

  • Chicken
  • Fish
  • Meat
  • Eggs
  • Dairy

A cooked portion of chicken, fish, or meat is about 2 to 3 ounces or about the size of a deck of cards. A portion of dairy foods is ½ cup of milk or yogurt, or one slice of cheese.

Plant-protein foods:

  • Beans
  • Nuts
  • Grains

A portion of cooked beans is about ½ cup, and a portion of nuts is ¼ cup. A portion of bread is a single slice, and a portion of cooked rice or cooked noodles is ½ cup.

Step 3: Choose foods that are healthy for your heart

Why? To help keep fat from building up in your blood vessels, heart, and kidneys. To help keep fat from building up in your blood vessels, heart, and kidneys.

  • Grill, broil, bake, roast, or stir-fry foods, instead of deep frying.
  • Cook with nonstick cooking spray or a small amount of olive oil instead of butter.
  • Trim fat from meat and remove skin from poultry before eating.
  • Try to limit saturated and trans fats. Read the food label.

Heart-healthy foods:

  • Lean cuts of meat, such as loin or round
  • Poultry without the skin
  • Fish
  • Beans
  • Vegetables
  • Fruits
  • Low-fat or fat-free milk, yogurt, and cheese

Limit alcohol

Drink alcohol only in moderation: no more than one drink per day if you are a woman, and no more than two if you are a man. Drinking too much alcohol can damage the liver, heart, and brain and cause serious health problems. Ask your health care provider how much alcohol you can drink safely.

A renal dietitian can help people learn about the amount and sources of protein in their diet. Animal protein in egg whites, cheese, chicken, fish, and red meats contain more of the essential nutrients a body needs. With careful meal planning, a well-balanced vegetarian diet can also provide these nutrients. A renal dietitian can help people with advanced chronic kidney disease make small adjustments in their eating habits that can result in significant protein reduction. For example, people can lower their protein intake by making sandwiches using thinner slices of meat and adding lettuce, cucumber slices, apple slices, and other garnishes. The following table lists some higher-protein foods and suggestions for lower-protein alternatives that are better choices for people with chronic kidney disease trying to limit their protein intake.

Why is it important to keep track of how much liquid you eat or drink ?

You may feel better if you keep track of and limit how much liquid you eat and drink. Excess fluid can build up in your body and may cause

  • swelling and weight gain between dialysis sessions
  • changes in your blood pressure
  • your heart to work harder, which can lead to serious heart trouble
  • a buildup of fluid in your lungs, making it hard for you to breathe

Hemodialysis removes extra fluid from your body. However, hemodialysis can remove only so much fluid at a time safely. If you come to your hemodialysis with too much fluid in your body, your treatment may make you feel ill. You may get muscle cramps or have a sudden drop in blood pressure that causes you to feel dizzy or sick to your stomach.

Your health care provider can help you figure out how much liquid is right for you.

One way to limit how much liquid you have is to limit the salt in the foods you eat. Salt makes you thirsty, so you drink more. Avoid salty foods such as chips and pretzels.

Your renal dietitian will give you other tips to help you limit how much liquid you consume while making sure you don’t feel too thirsty.

What foods count as liquid and why ?

Foods that are liquid at room temperature, such as soup, contain water. Gelatin, pudding, ice cream, and other foods that include a lot of liquid in the recipe also count. Most fruits and vegetables contain water, such as melons, grapes, apples, oranges, tomatoes, lettuce, and celery. When you count up how much liquid you have in a day, be sure to count these foods.

What is your dry weight ?

Your dry weight is your weight after a hemodialysis session has removed all extra fluid from your body. Controlling your liquid intake helps you stay at your proper dry weight. If you let too much fluid build up between sessions, it is harder to achieve your dry weight. Your health care provider can help you figure out what dry weight is right for you.

My dry weight goal: _____________.

Should you take vitamin and mineral supplements ?

You may not get enough vitamins and minerals in your diet because you have to avoid so many foods. Hemodialysis also removes some vitamins from your body. Your health care provider may prescribe a vitamin and mineral supplement designed specifically for people with kidney failure.

Warning: Do not take nutritional supplements you can buy over the counter. These supplements may contain vitamins or minerals that are harmful to you. For safety reasons, talk with your health care provider before using probiotics, dietary supplements, or any other medicine together with or in place of the treatment your health care provider prescribes.

What is acute kidney failure

Acute kidney failure occurs when your kidneys suddenly become unable to filter waste products from your blood 11. When your kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and your blood’s chemical makeup may get out of balance.

Acute kidney failure — also called acute renal failure or acute kidney injury — develops rapidly over a few hours or a few days 11. Acute kidney failure is most common in people who are already hospitalized, particularly in critically ill people who need intensive care.

Acute kidney failure can be fatal and requires intensive treatment 11. However, acute kidney failure may be reversible 11. If you’re otherwise in good health, you may recover normal or nearly normal kidney function 11.

What are Signs and Symptoms of Acute Kidney Failure

Signs and symptoms of acute kidney failure may include:

  • Decreased urine output, although occasionally urine output remains normal
  • Fluid retention, causing swelling in your legs, ankles or feet
  • Drowsiness
  • Shortness of breath
  • Fatigue
  • Confusion
  • Nausea
  • Seizures or coma in severe cases
  • Chest pain or pressure

Sometimes acute kidney failure causes no signs or symptoms and is detected through lab tests done for another reason.

Causes of Acute kidney failure

Acute kidney failure can occur when:

  • You have a condition that slows blood flow to your kidneys
  • You experience direct damage to your kidneys
  • Your kidneys’ urine drainage tubes (ureters) become blocked and wastes can’t leave your body through your urine

Impaired blood flow to the kidneys

Diseases and conditions that may slow blood flow to the kidneys and lead to kidney failure include:

  • Blood or fluid loss
  • Blood pressure medications
  • Heart attack
  • Heart disease
  • Infection
  • Liver failure
  • Use of aspirin, ibuprofen (Advil, Motrin IB, others), naproxen (Aleve, others) or related drugs
  • Severe allergic reaction (anaphylaxis)
  • Severe burns
  • Severe dehydration

Damage to the kidneys

These diseases, conditions and agents may damage the kidneys and lead to acute kidney failure:

  • Blood clots in the veins and arteries in and around the kidneys
  • Cholesterol deposits that block blood flow in the kidneys
  • Glomerulonephritis, inflammation of the tiny filters in the kidneys (glomeruli)
  • Hemolytic uremic syndrome, a condition that results from premature destruction of red blood cells
  • Infection
  • Lupus, an immune system disorder causing glomerulonephritis
  • Medications, such as certain chemotherapy drugs, antibiotics, dyes used during imaging tests and zoledronic acid (Reclast, Zometa), used to treat osteoporosis and high blood calcium levels (hypercalcemia)
  • Multiple myeloma, a cancer of the plasma cells
  • Scleroderma, a group of rare diseases affecting the skin and connective tissues
  • Thrombotic thrombocytopenic purpura, a rare blood disorder
  • Toxins, such as alcohol, heavy metals and cocaine
  • Vasculitis, an inflammation of blood vessels

Urine blockage in the kidneys

Diseases and conditions that block the passage of urine out of the body (urinary obstructions) and can lead to acute kidney failure include:

  • Bladder cancer
  • Blood clots in the urinary tract
  • Cervical cancer
  • Colon cancer
  • Enlarged prostate
  • Kidney stones
  • Nerve damage involving the nerves that control the bladder
  • Prostate cancer

Risk factors for Acute kidney failure

Acute kidney failure almost always occurs in connection with another medical condition or event. Conditions that can increase your risk of acute kidney failure include:

  • Being hospitalized, especially for a serious condition that requires intensive care
  • Advanced age
  • Blockages in the blood vessels in your arms or legs (peripheral artery disease)
  • Diabetes
  • High blood pressure
  • Heart failure
  • Kidney diseases
  • Liver diseases.

How to Prevent having an Acute Kidney Failure ?

Acute kidney failure is often difficult to predict or prevent. But you may reduce your risk by taking care of your kidneys. Try to:

  • Pay attention to labels when taking over-the-counter (OTC) pain medications. Follow the instructions for OTC pain medications, such as aspirin, acetaminophen (Tylenol, others) and ibuprofen (Advil, Motrin IB, others). Taking too much of these medications may increase your risk of acute kidney failure. This is especially true if you have pre-existing kidney disease, diabetes or high blood pressure.
  • Work with your doctor to manage kidney problems. If you have kidney disease or another condition that increases your risk of acute kidney failure, such as diabetes or high blood pressure, stay on track with treatment goals and follow your doctor’s recommendations to manage your condition.
  • Make a healthy lifestyle a priority. Be active; eat a sensible, balanced diet; and drink alcohol only in moderation — if at all.

Complications of acute kidney failure

Potential complications of acute kidney failure include:

  • Fluid buildup. Acute kidney failure may lead to a buildup of fluid in your lungs, which can cause shortness of breath.
  • Chest pain. If the lining that covers your heart (pericardium) becomes inflamed, you may experience chest pain.
  • Muscle weakness. When your body’s fluids and electrolytes — your body’s blood chemistry — are out of balance, muscle weakness can result. Elevated levels of potassium in your blood are particularly dangerous.
  • Permanent kidney damage. Occasionally, acute kidney failure causes permanent loss of kidney function, or end-stage renal disease. People with end-stage renal disease require either permanent dialysis — a mechanical filtration process used to remove toxins and wastes from the body — or a kidney transplant to survive.
  • Death. Acute kidney failure can lead to loss of kidney function and, ultimately, death. The risk of death is higher in people who had kidney problems before acute kidney failure.

Acute kidney failure diagnosis

If your signs and symptoms suggest that you have acute kidney failure, your doctor may recommend certain tests and procedures to verify your diagnosis. These may include:

  • Urine output measurements. The amount of urine you excrete in a day may help your doctor determine the cause of your kidney failure.
  • Urine tests. Analyzing a sample of your urine, a procedure called urinalysis, may reveal abnormalities that suggest kidney failure.
  • Blood tests. A sample of your blood may reveal rapidly rising levels of urea and creatinine — two substances used to measure kidney function.
  • Imaging tests. Imaging tests such as ultrasound and computerized tomography may be used to help your doctor see your kidneys.
  • Removing a sample of kidney tissue for testing. In some situations, your doctor may recommend a kidney biopsy to remove a small sample of kidney tissue for lab testing. Your doctor inserts a needle through your skin and into your kidney to remove the sample.

Treatment for acute kidney failure

Treatment for acute kidney failure typically requires a hospital stay. Most people with acute kidney failure are already hospitalized. How long you’ll stay in the hospital depends on the reason for your acute kidney failure and how quickly your kidneys recover.

In some cases, you may be able to recover at home.

Treating the underlying cause of your kidney failure

Treatment for acute kidney failure involves identifying the illness or injury that originally damaged your kidneys. Your treatment options depend on what’s causing your kidney failure.

Treating complications until your kidneys recover

Your doctor will also work to prevent complications and allow your kidneys time to heal. Treatments that help prevent complications include:

  • Treatments to balance the amount of fluids in your blood. If your acute kidney failure is caused by a lack of fluids in your blood, your doctor may recommend intravenous (IV) fluids. In other cases, acute kidney failure may cause you to have too much fluid, leading to swelling in your arms and legs. In these cases, your doctor may recommend medications (diuretics) to cause your body to expel extra fluids.
  • Medications to control blood potassium. If your kidneys aren’t properly filtering potassium from your blood, your doctor may prescribe calcium, glucose or sodium polystyrene sulfonate (Kayexalate, Kionex) to prevent the accumulation of high levels of potassium in your blood. Too much potassium in the blood can cause dangerous irregular heartbeats (arrhythmias) and muscle weakness.
  • Medications to restore blood calcium levels. If the levels of calcium in your blood drop too low, your doctor may recommend an infusion of calcium.
  • Dialysis to remove toxins from your blood. If toxins build up in your blood, you may need temporary hemodialysis — often referred to simply as dialysis — to help remove toxins and excess fluids from your body while your kidneys heal. Dialysis may also help remove excess potassium from your body. During dialysis, a machine pumps blood out of your body through an artificial kidney (dialyzer) that filters out waste. The blood is then returned to your body.

Home remedies for acute kidney failure

During your recovery from acute kidney failure, your doctor may recommend a special diet to help support your kidneys and limit the work they must do. Your doctor may refer you to a dietitian who can analyze your current diet and suggest ways to make your diet easier on your kidneys.

Depending on your situation, your dietitian may recommend that you:

  • Choose lower potassium foods. Your dietitian may recommend that you choose lower potassium foods. High-potassium foods include bananas, oranges, potatoes, spinach and tomatoes. Examples of low-potassium foods include apples, cabbage, green beans, grapes and strawberries.
  • Avoid products with added salt. Lower the amount of sodium you eat each day by avoiding products with added salt, including many convenience foods, such as frozen dinners, canned soups and fast foods. Other foods with added salt include salty snack foods, canned vegetables, and processed meats and cheeses.
  • Limit phosphorus. Phosphorus is a mineral found in foods, such as milk, cheese, dried beans, nuts and peanut butter. Too much phosphorus in your blood can weaken your bones and cause skin itchiness. Your dietitian can give you specific recommendations on phosphorus and how to limit it in your particular situation.

As your kidneys recover, you may no longer need to eat a special diet, although healthy eating remains important.

  1. Kidney Failure. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure[]
  2. Smith HW The Kidney: Structure and Function in Health and DiseaseNew YorkOxford Univ Pr, 1951, pg. 520-74[]
  3. Lindeman RD, TobinJ, ShockNW. Longitudinal studies on the rate of decline in renal function with age, J Am Geriatr Soc, 1985, vol. 33, pg. 278-85[]
  4. ManjunathG, TighiouartH, CoreshJ, MacleodB, SalemDN, GriffithJL. Level of kidney function as a risk factor for cardiovascular outcomes in the elderly, Kidney Int, 2003, vol. 63, pg. 1121-1129[]
  5. Aronoff GR, Berns JS, BrierME, GolperTA, MorrisonG, SingerI. Drug Prescribing in Renal Failure: Dosing Guidelines for AdultsPhiladelphiaAmerican College of Physicians, 2002[]
  6. CoreshJ, AstorBC, GreeneT, EknoyanG, LeveyAS. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey, Am J Kidney Dis, 2003, vol. 41, pg. 1-12[]
  7. ObradorGT, AroraPKauszAT, RuthazerR, PereiraBJ, LeveyAS. Level of renal function at the initiation of dialysis in the U.S. end-stage renal disease population, Kidney Int, 1999, vol. 56, pg. 2227-35[]
  8. Kidney failure. American Kidney Fund. http://www.kidneyfund.org/kidney-disease/kidney-failure/[]
  9. http://nkdep.nih.gov/professionals/gfr_calculators/gfr_faq.htm[]
  10. Eating Right for Chronic Kidney Disease. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/eating-nutrition[][]
  11. Acute kidney failure. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/kidney-failure/basics/definition/con-20024029[][][][][]
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12 Body SystemsKidneys

Kidney

kidney anatomy

Kidney

The paired kidneys are reddish, kidney bean–shaped organs located just above the waist between the peritoneum and the posterior wall of the abdomen. Because their position is posterior to the peritoneum of the abdominal cavity, the organs are said to be retroperitoneal (Figure 1). The kidneys are located between the levels of the last thoracic vertebrae T12 and third lumbar (L3) vertebrae, a position where they are partially protected by ribs 11 and 12. If these lower ribs are fractured, they can puncture the kidneys and cause significant, even life-threatening damage. The right kidney is slightly lower than the left (see Figure 1) because the liver occupies considerable space on the right side superior to the kidney.

A typical adult kidney is 10–12 cm (4–5 in.) long, 5–7 cm (2–3 in.) wide, and 3 cm (1 in.) thick—about the size of a bar of bath soap—and weighs about 135–150 g (4.5–5 oz). The concave medial border of each kidney faces the vertebral column (see Figure 2). Near the center of the concave border is an indentation called the renal hilum, through which the ureter emerges from the kidney along with blood vessels, lymphatic vessels, and nerves.

Three layers of tissue surround each kidney. The deep layer, the renal capsule, is a smooth, transparent sheet of dense irregular connective tissue that is continuous with the outer coat of the ureter. It serves as a barrier against trauma and helps maintain the shape of the kidney. The middle layer, the adipose capsule, is a mass of fatty tissue surrounding the renal capsule. It also protects the kidney from trauma and holds it firmly in place within the abdominal cavity. The superficial layer, the renal fascia, is another thin layer of dense irregular connective tissue that anchors the kidney to the surrounding structures and to the abdominal wall. On the anterior surface of the kidneys, the renal fascia is deep to the peritoneum.

Figure 1. Kidney location

kidney location

Figure 2. Kidney location (transverse section)

kidney location cross section

Kidney Anatomy

A frontal section through the kidney reveals two distinct regions: a superficial, light red region called the renal cortex and a deep, darker reddish-brown inner region called the renal medulla (medulla = inner portion) (Figure 3). The renal medulla consists of several cone-shaped renal pyramids. The base (wider end) of each pyramid faces the renal cortex, and its apex (narrower end), called a renal papilla, points toward the renal hilum. The renal cortex is the smooth-textured area extending from the renal capsule to the bases of the renal pyramids and into the spaces between them. It is divided into an outer cortical zone and an inner juxtamedullary zone. Those portions of the renal cortex that extend between renal pyramids are called renal columns.

Together, the renal cortex and renal pyramids of the renal medulla constitute the parenchyma or functional portion of the kidney. Within the parenchyma are the functional units of the kidney—about 1 million microscopic structures called nephrons. Filtrate (filtered fluid) formed by the nephrons drains into large papillary ducts, which extend through the renal papillae of the pyramids. The papillary ducts drain into cuplike structures called minor and major calyces. Each kidney has 8 to 18 minor calyces and 2 or 3 major calyces. A minor calyx receives filtrate from the papillary ducts of one renal papilla and delivers it to a major calyx. Once the filtrate enters the calyces it becomes urine because no further reabsorption can occur. The reason for this is that the simple epithelium of the nephron and ducts becomes transitional epithelium in the calyces. From the major calyces, urine drains into a single large cavity called the renal pelvis and then out through the ureter to the urinary bladder.

The hilum expands into a cavity within the kidney called the renal sinus, which contains part of the renal pelvis, the calyces, and branches of the renal blood vessels and nerves. Adipose tissue helps stabilize the position of these structures in the renal sinus.

Figure 3. Kidney anatomy

kidney anatomy

Figure 4. Kidney structure

kidney structure

Blood and Nerve Supply of the Kidneys

Because the kidneys remove wastes from the blood and regulate its volume and ionic composition, it is not surprising that they are abundantly supplied with blood vessels. Although the kidneys constitute less than 0.5% of total body mass, they receive 20–25% of the resting amount of blood pumped by the heart per minute via the right and left renal arteries (Figure 4 and 5). In adults, renal blood flow, the blood flow through both kidneys, is about 1200 mL per minute.

Within the kidney, the renal artery divides into several segmental arteries, which supply different segments (areas) of the kidney. Each segmental artery gives off several branches that enter the parenchyma and pass through the renal columns between the renal lobes as the interlobar arteries. A renal lobe consists of a renal pyramid, some of the renal column on either side of the renal pyramid, and the renal cortex at the base of the renal pyramid. At the bases of the renal pyramids, the interlobar arteries arch between the renal medulla and cortex; here they are known as the arcuate arteries.

Divisions of the arcuate arteries produce a series of cortical radiate (interlobular) arteries. These arteries radiate outward and enter the renal cortex. Here, they give off branches called afferent arterioles. Each nephron receives one afferent arteriole, which divides into a tangled, ball-shaped capillary network called the glomerulus. The glomerular capillaries then reunite to form an efferent arteriole that carries blood out of the glomerulus. Glomerular capillaries are unique among capillaries in the body because they are positioned between two arterioles, rather than between an arteriole and a venule. Because they are capillary networks and they also play an important role in urine formation, the glomeruli are considered part of both the cardiovascular and the urinary systems.

The efferent arterioles divide to form the peritubular capillaries, which surround tubular parts of the nephron in the renal cortex. Extending from some efferent arterioles are long, loop-shaped capillaries called vasa recta that supply tubular portions of the nephron in the renal medulla. The peritubular capillaries eventually reunite to form cortical radiate (interlobular) veins, which also receive blood from the vasa recta. Then the blood drains through the arcuate veins to the interlobar veins running between the renal pyramids. Blood leaves the kidney through a single renal vein that exits at the renal hilum and carries venous blood to the inferior vena cava.

Many renal nerves originate in the renal ganglion and pass through the renal plexus into the kidneys along with the renal arteries. Renal nerves are part of the sympathetic division of the autonomic nervous system. Most are vasomotor nerves that regulate the flow of blood through the kidney by causing vasodilation or vasoconstriction of renal arterioles.

Ultrafiltration of plasma is the main function of the glomeruli

Filtration is based on size and charge.

  • Small solutes cross readily.
  • Larger substances are generally restricted.
  • Negatively charged molecules are restricted.

Volume of ultrafiltrate = 135–180 liters(L)/day

  • 99% water reabsorbed 1–1.5 L urine excreted
  • Glomerular filtration rate (GFR) provides an estimate of how much blood is filtered by the kidneys each minute. In normal kidneys GFR > 60 ml/minute. A GFR of less than 60 ml/minute/1.73m² may mean you have kidney disease
  • The formula used to estimate GFR uses serum creatinine, age, gender, and race.
  • eGFR (mL/min/1.73 m2) = 175 x (serum creatinine)–1.154 x (Age)–0.203 x (0.742 if female) x (1.212 if African American)
  • Kidney failure is an eGFR < 15 ml/minute. Most people below this level need dialysis or a kidney transplant. Talk with your health care provider about your treatment options.
  • eGFR is not reliable for patients with rapidly changing creatinine levels, extremes in muscle mass and body size, or altered diet patterns.
  • For a free Glomerular Filtration Rate (GFR) Calculators please go here: https://www.niddk.nih.gov/health-information/communication-programs/nkdep/laboratory-evaluation/glomerular-filtration-rate-calculators

Table 1. Reference Table for Population Mean eGFR from NHANES III

Age (years)Mean eGFR (mL/min/1.73 m²)
20–29116
30–39107
40–4999
50–5993
60–6985
7075
[Source 1 ]

Figure 5. Microcirculation of the kidney

kidney microcirculation

Note: DCT = distal convoluted tubule; PCT = proximal convoluted tubule

Kidney function

The primary function of the kidneys is to help maintain homeostasis by regulating the composition (including pH) and the volume of the extracellular fluid. The kidneys accomplish this by removing metabolic wastes from the blood and combining the wastes with excess water and electrolytes to form urine, which they then excrete.

Kidneys maintain homeostasis

  1. Regulatory function
    • Control composition and volume of blood
    • Maintain stable concentrations of inorganic anions such as sodium (Na), potassium (K), and calcium (Ca)
    • Maintain acid-base balance
  2. Excretory function
    • Produce urine
    • Remove metabolic wastes including nitrogenous waste

Kidneys blood filtration and urine production

  • Filtration: Glomeruli generate ultrafiltrate of the plasma.
  • Reabsorption: Tubules selectively reabsorb substances from the ultrafiltrate.
  • Secretion: Tubules secrete substances into the urine.

Examples:

  • Potassium is reabsorbed from and secreted into the urine by the tubules.
  • Sodium is generally reabsorbed by the tubules.
  • Organic acids are secreted into the urine.
  • Albumin is generally reabsorbed within the tubules.

Damaged kidneys allow albumin to cross the filtration barrier into the urine

  • Increased glomerular permeability allows albumin (and other proteins) to cross the glomerulus into the urine.
  • Higher levels of protein within the tubule may exacerbate kidney damage by exceeding tubules’ ability to reabsorb the proteins.
  • An elevated urine albumin-to-creatinine ratio (UACR) is used to identify damaged kidneys. Urine albumin-to-creatinine ratio (UACR) results are used for screening, diagnosing, and treating chronic kidney disease. Forty percent of people are identified with chronic kidney disease on the basis of urine albumin alone.

The kidneys have several other important functions:

  • Produce Erythropoietin which stimulates marrow production of red blood cells.
  • Playing a role in the activation of vitamin D [activate 25(OH)D to 1,25 (OH)2D (active vitamin D)].
  • Helping to maintain blood volume and blood pressure by secreting the enzyme Renin.
  • Metabolize drugs and endogenous substances (e.g., insulin).

In patients with kidney failure:

  • Kidneys cannot maintain homeostasis.
  • Kidney failure is associated with fluid, electrolyte, and hormonal imbalances and metabolic abnormalities.
  • End stage kidney failure means the patient is on dialysis or has a kidney transplant.

Kidney problems

For about one-third of older people, kidney (also called renal) function remains steady throughout life. But for the rest of us, kidney function gradually starts to decline around age 35, sometimes worsening quickly in later years with increasing structural and hormonal changes. Your kidneys are normally more than capable of meeting the body’s demands, so there is a built-in reserve of kidney function, even as you age. Older kidneys, however, may not be as resilient as younger ones if they have been stressed. The result may be a higher risk of fluid imbalances, build-up of waste products, and other serious consequences in later years. Doses of medications must also be reduced if kidney function has declined, since your body can accumulate “overdose” levels if your kidneys cannot get rid of drugs efficiently.

Because the kidneys are important in regulating a variety of bodily functions, you may eventually develop problems requiring medical attention if your kidneys are not working well. These problems from kidney disease may include:

  • Fluid and electrolyte imbalance – for example, having too much or too little sodium, potassium, or water in your body
  • Build-up of waste products in your body—for example, urea or acids
  • Loss of protein through your kidneys
  • High blood pressure from too much fluid in your body
  • Anemia, or low blood counts
  • Brittle bones

If these problems become severe enough or don’t recover, you may end up needing dialysis – a procedure that uses a machine to wash out your blood to make up for the loss of kidney function.

Other kidney problems include:

  • Kidney Cancer
  • Kidney Cysts
  • Kidney Stones
  • Kidney Infections

Your doctor can do blood and urine tests to check if you have kidney disease. If your kidneys fail, you will need dialysis or a kidney transplant.

Symptoms of kidney disease

Kidney disease is called a ‘silent disease’ as there are often few or no symptoms. In fact, you can lose up to 90 per cent of your kidneys’ functionality before seeing any symptoms 2. Some signs and symptoms include:

  • a change in the frequency and quantity of urine passed, especially at night (usually an increase at first)
  • blood in the urine (hematuria)
  • foaming urine
  • puffiness around the eyes and ankles (edema)
  • pain in the back (under the lower ribs, where the kidneys are located)
  • pain or burning when passing urine.

If your kidneys begin to fail, there is a build-up of waste products and extra fluid in the blood, as well as other problems, gradually leading to:

  • tiredness and inability to concentrate
  • generally feeling unwell
  • loss of appetite
  • nausea and vomiting
  • shortness of breath.

Risk factors for kidney disease

You are more ‘at risk’ of developing chronic kidney disease if you:

  • have high blood pressure
  • have diabetes
  • have established heart problems (heart failure or past heart attack) or have had a stroke
  • are obese
  • are over 60 years of age
  • have a family history of kidney failure
  • smoke
  • have a history of acute kidney injury.

High blood pressure and kidney disease

High blood pressure (hypertension) is increased pressure inside the arteries that carry blood from your heart to all parts of your body. Untreated, high blood pressure can damage your kidneys.

Also, high blood pressure can develop as a result of kidney disease or renal artery stenosis (narrowing of the main artery to one or both kidneys). Your kidneys control the amount of fluid in your blood vessels and produce a hormone called renin that helps to control blood pressure.

Diabetes and kidney disease

About 20 to 30 per cent of people with diabetes develop a type of kidney disease called diabetic nephropathy. This is a serious disease and may worsen other diabetic complications such as nerve and eye damage, as well as increasing the risk of cardiovascular (heart) disease. Diabetic nephropathy is the main cause of kidney failure (also known as ‘end-stage kidney disease’ or ESKD).

Kidney disease and cardiovascular risks

Cardiovascular disease is the most common cause of death in people with chronic (ongoing) kidney disease. Compared to the general population, people with chronic kidney disease are two to three times more likely to have cardiovascular (heart and blood vessel) problems such as:

  • angina (heart pain)
  • heart attack
  • stroke
  • heart failure.

This increased risk is partly caused by factors common to both chronic kidney disease and cardiovascular disease, such as high blood pressure. However, researchers are discovering that chronic kidney disease is, in itself, an important risk factor for the development of cardiovascular disease, and a history of cardiovascular disease is a risk factor for the development of chronic kidney disease.

The kidneys regulate water and salts, remove certain wastes and make various hormones. Kidney disease increases the risk of cardiovascular disease in many ways, including:

  • high blood pressure – the kidneys help to regulate blood pressure by producing a hormone called renin. They also help to regulate the amount of salt and fluid in the body
  • heart strain – holding excess fluid in the body puts strain on the heart and increases the risk of complications such as left ventricular hypertrophy (enlarged left heart chamber), which can cause heart failure
  • stiff arteries – kidneys make a hormone that helps to regulate the use of calcium throughout the body. A person with chronic kidney disease may develop calcified (stiffened) arteries and heart valves, perhaps caused by hormones not being produced efficiently
  • increased blood fats (hyperlipidemia) – some people with chronic kidney disease have increased levels of low-density lipoprotein (LDL) “bad” cholesterol, which may be caused by disturbed hormone levels. High levels of LDL “bad” cholesterol is a known risk factor in the development of cardiovascular disease
  • blood clots – the blood of people with some types of chronic kidney disease, and those with kidney failure, is prone to clotting. A clot (thrombus) lodged within a blood vessel may cut off the blood supply. This increases the risk of many complications, including heart attack and stroke. A clot in one of the kidney arteries may cause high blood pressure.

Diagnosis of kidney disease

Early diagnosis and optimal management can often prevent kidney damage from becoming worse and reduce the risk of kidney failure.

Chronic kidney disease often has very few symptoms, or only general symptoms, such as tiredness, headaches and feeling sick. The doctor may begin by reviewing your medical history and performing a physical examination.

The diagnostic tests for kidney disease chosen by your doctor depend on factors including your symptoms, age, medical history, lifestyle and general health. Tests for kidney disease include:

  • urine tests
  • blood tests
  • imaging
  • kidney biopsy.

Urine tests for kidney disease

Damaged or inflamed kidneys ‘leak’ substances such as blood or protein into the urine. The preferred test for detecting protein in the urine is a urine albumin-to-creatinine ratio (urine ACR) test, which shows the amount of albumin (a type of protein) in the urine.

A urine albumin-to-creatinine ratio (urine ACR) test should be done at least once a year if the person has diabetes or high blood pressure, and every two years if the person has any of the other identified risk factors for developing chronic kidney disease.

A urine albumin-to-creatinine ratio (urine ACR) test is performed by sending a sample of your urine to a laboratory for analysis.

Blood tests for kidney disease

The best measure of kidney function is the glomerular filtration rate (GFR), which can be estimated from a blood test that checks the blood for creatinine (a waste product made by muscle tissue). A normal result is higher than 90 mL/min/1.73 m2. If the result is persistently less than 60 mL/min/1.73 m2 for at least three months, this confirms that the person has chronic kidney disease.

Blood tests can reveal other abnormalities of kidney function, such as:

  • high levels of acids (acidosis)
  • anemia (insufficient red blood cells or hemoglobin, the protein in red blood cells that transports oxygen)
  • high levels of potassium (hyperkalemia)
  • low levels of salt (hyponatremia)
  • changes to the levels of calcium and phosphate.

Imaging tests for kidney disease

Tests that create various pictures or images may include:

  • x-rays – to check the size of the kidneys and look for kidney stones
  • cystogram – a bladder x-ray
  • voiding cystourethrogram – where the bladder is x-rayed before and after urination
  • ultrasound – sound waves are ‘bounced’ off the kidneys to create a picture. Ultrasound may be used to check the size of the kidneys. Kidney stones and blood vessel blockages may be visible on ultrasound
  • computed tomography (CT) – x-rays and digital computer technology are used to create an image of the urinary tract, including the kidneys
  • magnetic resonance imaging (MRI) – a strong magnetic field and radio waves are used to create a three-dimensional image of the urinary tract, including the kidneys.

Biopsy for kidney disease

A biopsy means that a small piece of tissue is taken for testing in a laboratory. Biopsies used in the investigation of kidney disease may include:

  • Kidney biopsy – the doctor inserts a special needle into the back, under local anaesthesia, to obtain a small sample of kidney tissue. A kidney biopsy can confirm a diagnosis of chronic kidney disease.
  • Bladder biopsy – the doctor inserts a thin tube (cystoscope) into the bladder via the urethra. This allows the doctor to view the inside of the bladder and check for abnormalities. This procedure is called a cystoscopy. The doctor may take a biopsy of bladder tissue for examination in a laboratory.

Your doctor may arrange other tests, depending on the suspected cause of your kidney disorder.

Prevention of kidney disease

Medication and changes to lifestyle, along with an early referral to a kidney specialist (nephrologist), can prevent or delay kidney failure.

Healthy lifestyle choices to keep your kidneys functioning well include:

  • Eat lots of fruit and vegetables including legumes (peas or beans), and grain-based food such as bread, pasta, noodles and rice.
  • Eat lean meat such as chicken and fish each week.
  • Eat only small amounts of salty or fatty food.
  • Drink plenty of water instead of other drinks. Minimise consumption of sugary soft drinks.
  • Maintain a healthy weight.
  • Stay fit. Do at least 30 minutes of physical activity that increases your heart rate on five or more days of the week, including walking, lawn mowing, bike riding, swimming or gentle aerobics.
  • If you don’t smoke, don’t start. If you do, quit. Ask your doctor for help with quitting.
  • Limit your alcohol to no more than two small drinks per day if you are male, or one small drink per day if you are female.
  • Have your blood pressure checked regularly.
  • Do things that help you relax and reduce your stress levels.

A range of medication is available for high blood pressure. Different blood pressure medications work in different ways, so it is not unusual for more than one type to be prescribed. The dose may change according to your needs.

Treatment for kidney disease

If detected early enough, the progress of kidney disease can be slowed and sometimes even prevented. In the early stages, changes to diet and medication can help to increase the life of your kidneys.

If kidney function is reduced to less than 10 per cent of normal, the loss of function must be replaced by dialysis or a kidney transplant. Dialysis is a treatment for kidney failure that removes waste products and extra water from the blood by filtering it through a special membrane (fine filter).

Types of kidney diseases

Most kidney diseases attack the nephrons 3. This damage may leave kidneys unable to remove wastes. Causes can include genetic problems, injuries, or medicines. You have a higher risk of kidney disease if you have diabetes, high blood pressure, or a close family member with kidney disease.

Acute kidney injury

Acute kidney injury is sudden damage to the kidneys. In many cases it will be short term and your kidney function can continue to recover over time 4; however, long-term outcomes can vary from:

  • full recovery and normal kidney function
  • partial recovery with lower levels of kidney function, but no dialysis needed
  • permanent kidney damage that requires dialysis.

People who have a history of acute kidney injury have a higher risk of chronic kidney disease (see below Chronic kidney disease).

Causes of acute kidney injury

The main causes are:

  • reduced blood supply to the kidneys (for example as a result of major surgery or a heart attack)
  • damage to the actual kidney tissue caused by a drug, severe infection or radioactive dye
  • obstruction to urine leaving the kidney (for example because of kidney stones or an enlarged prostate).

People who have chronic kidney disease are also at increased risk of acute kidney injury.

Diagnosis for acute kidney injury

The kidney damage usually occurs quite quickly over a matter of days (compared to the months or years for chronic kidney disease to develop).

This leads to reduced output of urine, a sudden rise in toxins in the body, as well as a rapid build up of fluid.

Acute kidney injury may be diagnosed if you have a sharp increase in the levels of creatinine in your blood, or if your urine output is significantly decreased.

Treating acute kidney injury

The goals of treatment are to:

  • find and treat the cause of the acute kidney injury
  • use medications to support the kidneys
  • closely monitor the urine output and creatinine levels to check for toxins and assess kidney function.

Severe acute kidney injury may require dialysis treatment for one to two weeks while the kidneys recover.

Prognosis (outcome) of acute kidney injury

After acute kidney injury, long-term outcomes can vary from:

  • full recovery and normal kidney function
  • partial recovery with lower levels of kidney function, but no dialysis needed
  • permanent kidney damage that requires dialysis.

After an acute kidney injury your kidney function can continue to recover over time. People who have a history of acute kidney injury have a higher risk of chronic kidney disease.

It is recommended that you have a Kidney Health Check performed by your doctor every year for the first three years following an acute kidney injury.

The Kidney Health Check has three tests:

  1. A blood test to find out the level of waste products in your blood and calculate what’s called your estimated glomerular filtration rate (eGFR).
  2. A urine test to check for albumin (a type of protein) or blood in your urine.
  3. A blood pressure test, as kidney disease causes high blood pressure and high blood pressure causes kidney disease.

If kidney disease is suspected, your doctor may also organize a renal ultrasound scan. This test is taken to show the size of your kidneys, locate kidney stones or tumours, and find any problems in the structure of your kidneys and urinary tract.

Following your Kidney Health Check and depending on your circumstances, other tests and procedures may be required.

  • If you have one or more risk factors for chronic kidney disease it is recommended that you see your doctor for a Kidney Health Check every two years.
  • If you have diabetes or high blood pressure it is recommended that you have a Kidney Health Check every year.

These tests may be carried out by your doctor or you may be referred to a kidney specialist (nephrologist).

Chronic kidney disease

Chronic kidney disease also known as CKD or chronic kidney failure, is a long-term condition (chronic or more than 3 months) where your kidneys are damaged and lose their ability to filter waste and fluid out of your blood. Chronic kidney disease is called “chronic” because the damage to your kidneys happens slowly over a long period of time. Advanced chronic kidney disease can cause dangerous levels of fluid, electrolytes, toxins and wastes to build up in your body and harm your health. A person is said to have chronic kidney disease (CKD) if they have abnormalities of kidney function or structure present for more than 3 months. If the kidney damage is severe, your kidneys may stop working. This is called kidney failure and it means you will need dialysis or a kidney transplant. The medical definition of CKD includes all individuals with markers of kidney damage or those with an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m² on at least 2 occasions 90 days apart (with or without markers of kidney damage) 5. A normal eGFR is above 90mL/min/1.73m². Markers of kidney disease may include: albuminuria (albumin:creatinine ratio [ACR] > 3 mg/mmol), presence of blood in urine (hematuria) (or presumed or confirmed renal origin), electrolyte abnormalities due to tubular disorders, renal histological abnormalities, structural abnormalities detected by imaging (e.g. polycystic kidneys, reflux nephropathy) or a history of kidney transplantation 5.

Chronic kidney disease is a common condition often associated with getting older. Chronic kidney disease can affect anyone, but it’s more common in people who are black or of south Asian origin.

CKD can get worse over time and eventually the kidneys may stop working altogether or end-stage renal disease (ESRD) is when your kidneys have stopped working well enough for you to survive without dialysis or a kidney transplant, but this is uncommon. Many people with CKD are able to live long lives with the condition. In the U.S., 37 million people have CKD 6. That is more than 1 in 7 adults.

Many people with chronic kidney disease (CKD) will not have symptoms because it does not usually cause problems until it reaches an advanced stage. CKD may only be diagnosed if you have a blood or urine test for another reason and the results show a possible problem with your kidneys.

The diagnosis of CKD requires the following:

  • Decline of kidney function for 3 months or more AND
  • Evidence of kidney damage (e.g. albuminuria or abnormal biopsy) OR
  • GFR <60 mL/min/1.73 m²

At a more advanced kidney disease stage, symptoms can include:

  • tiredness
  • swollen ankles, feet or hands
  • shortness of breath
  • feeling sick
  • blood in your pee (urine)

Damage to your kidneys cannot be reversed. But if doctors find CKD early, there are ways you can keep the damage from getting worse, such as following a kidney-friendly eating plan, being active and taking certain medicines. If you have a medical condition that increases your risk of kidney disease, your doctor may monitor your blood pressure and kidney function with urine and blood tests during office visits.

Treatment for chronic kidney disease focuses on slowing the progression of kidney damage, usually by controlling the cause. But, even controlling the cause might not keep kidney damage from progressing. Chronic kidney disease can progress to end-stage kidney failure, which is fatal without artificial filtering (dialysis) or a kidney transplant.

CKD stages

CKD stages

Each chronic kidney disease patient is classified into one of the following 5 stages of CKD based on their estimated glomerular filtration rate (eGFR) and the level of proteinuria, because management and prognosis varies according to the progression of damage.

  • CKD Stage 1: Kidney damage with normal or increased eGFR (above 90 mL/min/1.73 m²), but other tests have detected signs of kidney damage
  • CKD Stage 2: Mild reduction in eGFR (60-89 mL/min/1.73 m²), with other signs of kidney damage
  • CKD Stage 3: Moderate reduction in eGFR (30-59 mL/min/1.73 m²)
    • Stage 3a (G3a) – an eGFR of 45 to 59ml/min/1.73 m²
    • Stage 3b (G3b) – an eGFR of 30 to 44ml/min/1.73 m²
  • CKD Stage 4: Severe reduction in eGFR (15-29 mL/min/1.73 m²)
  • CKD Stage 5 (End Stage Kidney Disease or ESRD): Kidney failure (eGFR less than 15 mL/min/1.73 m²), meaning the kidneys have lost almost all of their function and require dialysis

Alongside your eGFR, your urine albumin:creatinine ratio (ACR) can help give a more accurate picture of how well your kidneys are working.

Your albumin:creatinine ratio (ACR) result is given as a stage from 1 to 3:

  • A1 – an ACR of less than 3mg/mmol
  • A2 – an ACR of 3 to 30mg/mmol
  • A3 – an ACR of more than 30mg/mmol

For both eGFR and ACR, a higher stage indicates more severe kidney disease.

Figure 6. CKD stages

Stages-of-Chronic-Kidney-Disease

Chronic kidney disease causes

Chronic kidney disease is usually caused by other disease or condition that impairs kidney function, causing kidney damage to worsen over several months or years such as a disease like diabetes or high blood pressure. Diabetes means that your blood sugar is too high and diabetes is the most common cause of kidney failure. High blood pressure is the second most common cause of kidney failure. Chronic kidney disease is often the result of a combination of different problems.

CKD can be caused by:

You can help prevent CKD by making healthy lifestyle changes and ensuring any underlying conditions you have are well controlled.

Risk factors for developing CKD

Risk factors are things that give you a higher chance of having a condition, such as kidney disease. Having one of these risk factors does not mean that you will get kidney disease. But if you do, and you find and treat kidney disease early, you may be able to prevent it from getting worse.

Risk factors that can increase your risk of chronic kidney disease include:

  • Diabetes. Diabetes is the leading risk factor for kidney disease and the most common cause of kidney failure. High blood sugar from diabetes damages your kidneys and lowers their ability to filter waste and fluid from your blood. Over time, this causes kidney disease. If you have diabetes, healthy eating, being active and taking medicine can help slow or avoid damage to your kidneys.
  • High blood pressure. High blood pressure is a leading risk factor for kidney disease and the second most common cause of kidney failure, after diabetes. When you have high blood pressure, the force of your blood flowing through the tiny blood vessels in your kidneys can cause damage. High blood pressure can also be a symptom of kidney disease. Keeping your blood pressure under control can help prevent kidney disease or keep it from getting worse.
  • Heart (cardiovascular) disease
  • Smoking
  • Obesity
  • Being Black, Native American or Asian American
  • Family history of kidney disease
  • Abnormal kidney structure
  • Older age
  • Frequent use of medications that can damage the kidneys.

Chronic kidney disease prevention

To reduce your risk of developing kidney disease:

  • Follow instructions on over-the-counter medications. When using nonprescription pain relievers, such as aspirin, ibuprofen (Advil, Motrin IB, others) and acetaminophen (Tylenol, others), follow the instructions on the package. Taking too many pain relievers for a long time could lead to kidney damage.
  • Maintain a healthy weight. If you’re at a healthy weight, maintain it by being physically active most days of the week. If you need to lose weight, talk with your doctor about strategies for healthy weight loss.
  • Don’t smoke. Cigarette smoking can damage your kidneys and make existing kidney damage worse. If you’re a smoker, talk to your doctor about strategies for quitting. Support groups, counseling and medications can all help you to stop.
  • Manage your medical conditions with your doctor’s help. If you have diseases or conditions that increase your risk of kidney disease, work with your doctor to control them. Ask your doctor about tests to look for signs of kidney damage.

Chronic kidney disease signs and symptoms

Signs and symptoms of chronic kidney disease develop over time if kidney damage progresses slowly. In the early stages of chronic kidney disease, you might have few signs or symptoms. You might not realize that you have kidney disease until the condition is advanced. This is because your kidneys have a greater capacity to do their job than is needed to keep you healthy. For example, you can donate one kidney and remain healthy. You can also have kidney damage without any symptoms because, despite the damage, your kidneys are still doing enough work to keep you feeling well. For many people, the only way to know if you have kidney disease is to get your kidneys checked with blood and urine tests.

Loss of kidney function can cause a buildup of fluid or body waste or electrolyte problems. Depending on how severe it is, loss of kidney function can cause:

  • Nausea
  • Vomiting
  • Loss of appetite
  • Fatigue and weakness
  • Sleep problems
  • Urinating more or less
  • Decreased mental sharpness
  • Muscle cramps
  • Swelling of feet and ankles
  • Dry, itchy skin
  • High blood pressure (hypertension) that’s difficult to control
  • Shortness of breath, if fluid builds up in the lungs
  • Chest pain, if fluid builds up around the lining of the heart

Signs and symptoms of kidney disease are often nonspecific. This means they can also be caused by other illnesses. Because your kidneys are able to make up for lost function, you might not develop signs and symptoms until irreversible damage has occurred.

Make an appointment with your doctor if you have signs or symptoms of kidney disease. Early detection might help prevent kidney disease from progressing to kidney failure.

Early stages of CKD

Kidney disease does not tend to cause symptoms when it’s at an early stage. This is because the body is usually able to cope with a significant reduction in kidney function. Kidney disease is often only diagnosed at this stage if a routine test for another condition, such as a blood or urine test, detects a possible problem. If it’s found at an early stage, medicine and regular tests to monitor it may help stop it becoming more advanced.

Later stages of CKD

A number of symptoms can develop if kidney disease is not found early or it gets worse despite treatment.

Later stages of CKD symptoms can include:

  • weight loss and poor appetite
  • swollen ankles, feet or hands – as a result of water retention (edema)
  • shortness of breath
  • tiredness
  • blood in your pee (urine)
  • an increased need to pee – particularly at night
  • difficulty sleeping (insomnia)
  • itchy skin
  • muscle cramps
  • feeling sick
  • headaches
  • erectile dysfunction in men

People with late stage CKD can also develop anemia, bone disease, and malnutrition. This stage of CKD is known as kidney failure, end-stage renal disease or established renal failure. It may eventually require treatment with dialysis or a kidney transplant.

Chronic kidney disease complications

Chronic kidney disease can affect almost every part of your body. Potential complications include:

  • Fluid retention, which could lead to swelling in your arms and legs, high blood pressure, or fluid in your lungs (pulmonary edema)
  • A sudden rise in potassium levels in your blood (hyperkalemia), which could impair your heart’s function and can be life-threatening
  • Anemia
  • Heart disease. If you have kidney disease, it increases your chances of having a stroke or heart attack.
  • High blood pressure can be both a cause and a result of kidney disease. High blood pressure damages your kidneys, and damaged kidneys don’t work as well to help control your blood pressure.
  • Weak bones and an increased risk of bone fractures
  • Decreased sex drive, erectile dysfunction or reduced fertility
  • Damage to your central nervous system, which can cause difficulty concentrating, personality changes or seizures
  • Decreased immune response, which makes you more vulnerable to infection
  • Pericarditis, an inflammation of the saclike membrane that envelops your heart (pericardium)
  • Pregnancy complications that carry risks for the mother and the developing fetus
  • Irreversible damage to your kidneys (end-stage kidney disease), eventually requiring either dialysis or a kidney transplant for survival

If you have CKD, you also have a higher chance of having a sudden change in kidney function caused by illness, injury, or certain medicines. This is called acute kidney injury (AKI).

Chronic kidney disease diagnosis

As a first step toward diagnosis of kidney disease, your doctor discusses your personal and family history with you. Among other things, your doctor might ask questions about whether you’ve been diagnosed with high blood pressure, if you’ve taken a medication that might affect kidney function, if you’ve noticed changes in your urinary habits and whether you have family members who have kidney disease.

Next, your doctor performs a physical exam, checking for signs of problems with your heart or blood vessels, and conducts a neurological exam.

For kidney disease diagnosis, you might also need certain tests and procedures to determine how severe your kidney disease is (stage).

Chronic kidney disease (CKD) can be diagnosed with blood and urine tests. In many cases, CKD is only found when a routine blood or urine test you have for another problem shows that your kidneys may not be working normally.

Blood test

The main test for kidney disease is a blood test. The test measures the levels of a waste product called creatinine and urea in your blood. Your doctor uses your blood test results, plus your age, size, gender and ethnic group to calculate how many milliliters (mL) of waste your kidneys should be able to filter in a minute. This calculation is known as your estimated glomerular filtration rate (eGFR). Healthy kidneys should be able to filter more than 90mL/min. You may have CKD if your rate is lower than this.

Your test results can be used to determine how damaged your kidneys are, known as the stage of CKD.

This can help your doctor decide the best treatment for you and how often you should have tests to monitor your condition.

The Glomerular filtration rate (GFR) provides an estimate of how much blood is filtered by the kidneys each minute.

Table 1. Reference Table for Population Mean eGFR from NHANES III

Age (years)Mean eGFR (mL/min/1.73 m²)
20–29116
30–39107
40–4999
50–5993
60–6985
7075
[Source 1]

Each chronic kidney disease patient is classified into one of the following 5 stages of CKD based on their estimated glomerular filtration rate (eGFR) and the level of proteinuria, because management and prognosis varies according to the progression of damage.

  • CKD Stage 1: Kidney damage with normal or increased eGFR (above 90 mL/min/1.73 m²), but other tests have detected signs of kidney damage
  • CKD Stage 2: Mild reduction in eGFR (60-89 mL/min/1.73 m²), with other signs of kidney damage
  • CKD Stage 3: Moderate reduction in eGFR (30-59 mL/min/1.73 m²)
    • Stage 3a (G3a) – an eGFR of 45 to 59ml/min/1.73 m²
    • Stage 3b (G3b) – an eGFR of 30 to 44ml/min/1.73 m²
  • CKD Stage 4: Severe reduction in eGFR (15-29 mL/min/1.73 m²)
  • CKD Stage 5 (End Stage Kidney Disease or ESRD): Kidney failure (eGFR less than 15 mL/min/1.73 m²), meaning the kidneys have lost almost all of their function and require dialysis

Alongside your eGFR, your urine albumin:creatinine ratio (ACR) can help give a more accurate picture of how well your kidneys are working.

Urine test

A urine test is also done to:

  • check the levels of substances called albumin and creatinine in your urine – known as the albumin:creatinine ratio, or ACR
  • check for blood or protein in your urine. Healthy kidneys usually almost completely prevent certain substances in the blood from entering the urine. Kidney damage may become noticeable when blood or protein are found in urine. Examples include blood proteins like albumin. Blood and protein are only found in significant amounts in urine if the kidneys are damaged. The amount of protein in urine is taken as a sign of how bad the damage is.

Alongside your eGFR, your urine albumin:creatinine ratio (ACR) can help give a more accurate picture of how well your kidneys are working.

Your albumin:creatinine ratio (ACR) result is given as a stage from 1 to 3:

  • A1 – an ACR of less than 3 mg/mmol
  • A2 – an ACR of 3 to 30 mg/mmol
  • A3 – an ACR of more than 30 mg/mmol

For both eGFR and ACR, a higher stage indicates more severe kidney disease.

Other tests

Sometimes other tests are also used to assess the level of damage to your kidneys.

These may include:

  • an ultrasound scan, MRI scan or CT scan – to see what the kidneys look like and check whether there are any blockages
  • a kidney biopsy – a small sample of kidney tissue is removed using a needle and the cells are examined under a microscope for signs of damage. Kidney biopsy is often done with local anesthesia using a long, thin needle that’s inserted through your skin and into your kidney. The biopsy sample is sent to a lab for testing to help determine what’s causing your kidney problem.

Chronic kidney disease treatment

There’s no cure for chronic kidney disease (CKD). Depending on the cause, some types of kidney disease can be treated. Your treatment will depend on the stage of your CKD. Treatment usually consists of measures to help control signs and symptoms, reduce complications, and slow progression of the kidney disease. If your kidneys become severely damaged, you might need treatment for end-stage kidney disease.

The main treatments for chronic renal failure are:

  • Treating the cause of your kidney disease
  • Lifestyle changes – to help you stay as healthy as possible
  • Medicine – to control associated problems, such as high blood pressure and high cholesterol
  • Dialysis – treatment to replicate some of the kidney’s functions, which may be necessary in advanced (stage 5) CKD
  • Kidney transplant – this may also be necessary in advanced (stage 5) CKD

Treating the cause of your kidney disease

Your doctor will work to slow or control the cause of your kidney disease. Treatment options vary depending on the cause. But kidney damage can continue to worsen even when an underlying condition, such as diabetes mellitus or high blood pressure, has been controlled.

Lifestyle changes for people with chronic kidney disease

The following lifestyle measures are usually recommended for people with kidney disease:

  • stop smoking if you smoke
  • eat a healthy, balanced diet
  • restrict your salt intake to less than 6g a day – that’s around 1 teaspoon
  • do regular exercise – aim to do at least 150 minutes a week
  • manage your alcohol intake so you drink no more than the recommended limit of 14 units of alcohol a week
  • lose weight if you’re overweight or obese
  • avoid over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, except when advised to by a medical professional – these medicines can harm your kidneys if you have kidney disease

Treating complications

Kidney disease complications can be controlled to make you more comfortable. Treatments might include:

  • High blood pressure medications. People with kidney disease can have worsening high blood pressure. Your doctor might recommend medications to lower your blood pressure — commonly angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers — and to preserve kidney function. High blood pressure medications can initially decrease kidney function and change electrolyte levels, so you might need frequent blood tests to monitor your condition. Your doctor may also recommend a water pill (diuretic) and a low-salt diet.
  • Medications to relieve swelling. People with chronic kidney disease often retain fluids. This can lead to swelling in the legs as well as high blood pressure. Medications called diuretics can help maintain the balance of fluids in your body.
  • Medications to treat anemia. Supplements of the hormone erythropoietin (EPO), sometimes with added iron, help produce more red blood cells. This might relieve fatigue and weakness associated with anemia.
  • Medications to lower cholesterol levels. Your doctor might recommend medications called statins to lower your cholesterol. People with chronic kidney disease often have high levels of bad cholesterol, which can increase the risk of heart disease.
  • Medications to protect your bones. Hyperphosphatemia is a frequent complication of CKD due to a decreased filtered load of phosphorous. This leads to increased secretion of a parathyroid hormone (PTH) and causes secondary hyperparathyroidism. Hyperparathyroidism results in the normalization of phosphorous and calcium but at the expense of bone. This results in renal osteodystrophy. Therefore, phosphorus binders along with dietary restriction of phosphorus are used to treat secondary hyperparathyroidism. Calcium and vitamin D supplements can help prevent weak bones and lower your risk of fracture. You might also take medication known as a phosphate binder to lower the amount of phosphate in your blood and protect your blood vessels from damage by calcium deposits (calcification).
  • A lower protein diet to minimize waste products in your blood. As your body processes protein from foods, it creates waste products that your kidneys must filter from your blood. To reduce the amount of work your kidneys must do, your doctor might recommend eating less protein. A registered dietitian can suggest ways to lower your protein intake while still eating a healthy diet.

Your doctor might recommend regular follow-up testing to see whether your kidney disease remains stable or progresses.

Treatment for end-stage kidney disease

If your kidneys can’t keep up with waste and fluid clearance on their own and you develop complete or near-complete kidney failure, you have end-stage kidney disease. At that point, you need dialysis or a kidney transplant.

  • Dialysis. Dialysis artificially removes waste products and extra fluid from your blood when your kidneys can no longer do this. In hemodialysis, a machine filters waste and excess fluids from your blood. In peritoneal dialysis, a thin tube inserted into your abdomen fills your abdominal cavity with a dialysis solution that absorbs waste and excess fluids. After a time, the dialysis solution drains from your body, carrying the waste with it.
  • Kidney transplant. A kidney transplant involves surgically placing a healthy kidney from a donor into your body. Transplanted kidneys can come from deceased or living donors. After a transplant, you’ll need to take medications for the rest of your life to keep your body from rejecting the new organ. You don’t need to be on dialysis to have a kidney transplant.

For some who choose not to have dialysis or a kidney transplant, a third option is to treat your kidney failure with conservative measures. Conservative measures likely will include symptom management, advance care planning and care to keep you comfortable (palliative care).

Kidney Cancer

Kidney cancer is a disease that starts in the kidneys 8. It happens when healthy cells in one or both kidneys grow out of control and form a lump (called a tumor).

Types of kidney cancer

Renal cell carcinoma

Renal cell carcinoma, also known as renal cell cancer or renal cell adenocarcinoma, is by far the most common type of kidney cancer. About 9 out of 10 kidney cancers are renal cell carcinomas 9.

Although renal cell carcinoma usually grows as a single tumor within a kidney, sometimes there are 2 or more tumors in one kidney or even tumors in both kidneys at the same time.

There are several subtypes of renal cell carcinoma, based mainly on how the cancer cells look under a microscope. Knowing the subtype of renal cell carcinoma can be a factor in deciding treatment and can also help your doctor determine if your cancer might be due to an inherited genetic syndrome.

Clear cell renal cell carcinoma: this is the most common form of renal cell carcinoma. About 7 out of 10 people with renal cell carcinoma have this kind of cancer. When seen under a microscope, the cells that make up clear cell renal cell carcinoma look very pale or clear.

Papillary renal cell carcinoma: this is the second most common subtype – about 1 in 10 renal cell carcinomas are of this type. These cancers form little finger-like projections (called papillae) in some, if not most, of the tumor. Some doctors call these cancers chromophilic because the cells take in certain dyes and look pink under the microscope.

Chromophobe renal cell carcinoma: this subtype accounts for about 5% (5 cases in 100) of renal cell carcinomas. The cells of these cancers are also pale, like the clear cells, but are much larger and have certain other features that can be recognized when looked at with a microscope .

Rare types of renal cell carcinoma: these subtypes are very rare, each making up less than 1% of renal cell carcinomas:

  • Collecting duct renal cell carcinoma
  • Multilocular cystic renal cell carcinoma
  • Medullary carcinoma
  • Mucinous tubular and spindle cell carcinoma
  • Neuroblastoma-associated renal cell carcinoma

Unclassified renal cell carcinoma: rarely, renal cell cancers are labeled as unclassified because the way they look doesn’t fit into any of the other categories or because there is more than one type of cell present.

Other types of kidney cancers

Other types of kidney cancers include transitional cell carcinomas, Wilms tumors, and renal sarcomas.

Transitional cell carcinoma: of every 100 cancers in the kidney, about 5 to 10 are transitional cell carcinomas, also known as urothelial carcinomas.

Transitional cell carcinomas don’t start in the kidney itself, but in the lining of the renal pelvis (where the ureters meet the kidneys). This lining is made up of cells called transitional cells that look like the cells that line the ureters and bladder. Cancers that develop from these cells look like other urothelial carcinomas, such as bladder cancer, under the microscope. Like bladder cancer, these cancers are often linked to cigarette smoking and being exposed to certain cancer-causing chemicals in the workplace.

People with transitional cell carcinoma often have the same signs and symptoms as people with renal cell cancer − blood in the urine and, sometimes, back pain.

Wilms tumor (nephroblastoma): Wilms tumors almost always occur in children. This type of cancer is very rare among adults.

Renal sarcoma: renal sarcomas are a rare type of kidney cancer that begin in the blood vessels or connective tissue of the kidney. They make up less than 1% of all kidney cancers.

Benign (non-cancerous) kidney tumors

Some kidney tumors are benign (non-cancerous). This means they do not metastasize (spread) to other parts of the body, although they can still grow and cause problems.

Benign kidney tumors can be treated by removing or destroying them, using many of the same treatments that are also used for kidney cancers, such as surgery, radiofrequency ablation, and arterial embolization. The choice of treatment depends on many factors, such as the size of the tumor and if it is causing any symptoms, the number of tumors, whether tumors are in both kidneys, and the person’s general health.

Renal adenoma: renal adenomas are the most common benign kidney tumors. They are small, slow-growing tumors that are often found on imaging tests (such as CT scans) when the doctor is looking for something else. Seen with a microscope, they look a lot like low-grade (slow growing) renal cell carcinomas.

In rare cases, tumors first thought to be renal adenomas turn out to be small renal cell carcinomas. Because they are hard to tell apart, suspected adenomas are often treated like renal cell cancers.

Oncocytoma: oncocytomas are benign kidney tumors that can sometimes grow quite large. As with renal adenomas, it can sometimes be hard to tell them apart from kidney cancers. Oncocytomas do not normally spread to other organs, so surgery often cures them.

Angiomyolipoma: angiomyolipomas are rare. They often develop in people with tuberous sclerosis, a genetic condition that also affects the heart, eyes, brain, lungs, and skin. These tumors are made up of different types of connective tissues (blood vessels, smooth muscles, and fat). If they aren’t causing any symptoms, they can often just be watched closely. If they start causing problems (like pain or bleeding), they may need to be treated.

The American Cancer Society’s most recent estimates for kidney cancer in the United States are for 2017 10:

  • About 63,990 new cases of kidney cancer (40,610 in men and 23,380 in women) will occur.
  • About 14,400 people (9,470 men and 4,930 women) will die from this disease.

These numbers include all types of kidney and renal pelvis cancers.

Most people with kidney cancer are older. The average age of people when they are diagnosed is 64. Kidney cancer is very uncommon in people younger than age 45.

Kidney cancer is among the 10 most common cancers in both men and women. Overall, the lifetime risk for developing kidney cancer is about 1 in 63 (1.6%). This risk is higher in men than in women.

For reasons that are not totally clear, the rate of new kidney cancers has been rising since the 1990s, although this seems to have leveled off in the past few years. Part of this rise was probably due to the use of newer imaging tests such as CT scans, which picked up some cancers that might never have been found otherwise. The death rates for these cancers have gone down slightly since the middle of the 1990s.

Studies show there is a link between kidney cancer and kidney disease. Some studies show that people with kidney disease may have a higher risk for kidney cancer. On the other hand, about one-third of the 300,000 kidney cancer survivors in the United States have or will develop kidney disease 11. Some reasons are:

  • Long-term dialysis. Some studies show that people on long-term dialysis have an increased risk for kidney cancer. Experts believe this risk is due to kidney disease rather than dialysis.
  • Surgery on the kidney (called “nephrectomy”). Your risk for kidney disease is higher if all (rather than part) of the kidney must be removed due to cancer. If the tumor is small, it is better to remove only the tumor, but not the whole kidney. This lessens your chance of developing kidney disease. However, removing all of the kidney is often better for your survival if the tumor is large or centrally located.
  • Immunosuppressant medicines. Some anti-rejection medicines that must be taken by kidney transplant recipients to prevent rejection can increase your risk for kidney cancer. However, taking your immunosuppressant medicine is important if you have a transplant. Without it, your body will reject your new kidney.

Remember, not everyone with kidney cancer will get kidney disease. Likewise, not everyone who has kidney disease or a transplant will get kidney cancer. Ask your healthcare provider what you can do to lessen your risk.

What treatments are used to treat kidney cancer?

There are several ways to treat kidney cancer, depending on its type and stage.

Local treatments: Some treatments are called local therapies, meaning they treat the tumor without affecting the rest of the body. Types of local therapy used for kidney cancer include:

  • Surgery
  • Ablation and other local therapies
  • Active surveillance
  • Radiation therapy

These treatments are more likely to be useful for earlier stage (less advanced) cancers, although they might also be used in some other situations.

Systemic treatments: Kidney cancer can also be treated using drugs, which can be given by mouth or directly into the bloodstream. These are called systemic therapies because they can reach cancer cells almost anywhere in the body. Depending on the type of kidney cancer, several different types of drugs might be used, including:

  • Targeted therapy
  • Immunotherapy (biologic therapy)
  • Chemotherapy

Depending on the stage of the cancer and other factors, different types of treatment may be combined at the same time or used after one another.

Some of these treatments can also be used as palliative treatment when all the cancer cannot be removed. Palliative treatment is meant to relieve symptoms, such as pain, but it is not expected to cure the cancer.

Kidney Stones

A kidney stone is a solid piece of material that forms in the kidney from substances in the urine 12. It may be as small as a grain of sand or as large as a pearl. Most kidney stones pass out of the body without help from a doctor. But sometimes a stone will not go away. It may get stuck in the urinary tract, block the flow of urine and cause great pain.

Depending on your situation, you may need nothing more than to take pain medication and drink lots of water to pass a kidney stone. In other instances — for example, if stones become lodged in the urinary tract, are associated with a urinary infection or cause complications — surgery may be needed.

The following may be signs of kidney stones that need a doctor’s help:

  • Extreme pain in your back or side below the ribs that will not go away
  • Pink, red or brown urine
  • Fever and chills if an infection is present
  • Nausea and vomiting
  • Urine that smells bad or looks cloudy
  • A burning feeling when you urinate
  • Pain that radiates to the lower abdomen and groin
  • Pain that comes in waves and fluctuates in intensity
  • Pain on urination
  • Persistent need to urinate
  • Urinating more often than usual
  • Urinating small amounts

Your doctor will diagnose a kidney stone with urine, blood, and imaging tests.

If you have a stone that won’t pass on its own, you may need treatment. It can be done with shock waves; with a scope inserted through the tube that carries urine out of the body, called the urethra; or with surgery.

Your doctor may recommend preventive treatment to reduce your risk of recurrent kidney stones if you’re at increased risk of developing them again.

Kidney Infections

Kidney infection (pyelonephritis) is a type of urinary tract infection (UTI) that generally begins in your urethra or bladder and travels to one or both of your kidneys 13. Most kidney infections are caused by bacteria or viruses that first infect your lower urinary tract, usually your bladder 14. Then, the infection moves upstream to one or both of your kidneys, which are part of the upper urinary tract.

In some cases, you can get a kidney infection after surgery if bacteria enter your body during the procedure and travel through your blood to the kidneys.

Your body has ways to defend against infections in the urinary tract. For example, urine normally flows one way from your kidneys to your bladder. Viruses or bacteria that enter are flushed out by urinating. This one-way flow of urine usually prevents an infection in your urinary tract.

Sometimes your body’s defenses fail and bacteria or viruses cause a urinary tract infection (UTI) in the bladder. If you have symptoms of a bladder infection, see a health care professional. You may need treatment to prevent the infection from spreading to your kidneys. Kidney infections are often very painful and can cause serious health problems.

A kidney infection requires prompt medical attention. If not treated properly, a kidney infection can permanently damage your kidneys or the bacteria can spread to your bloodstream and cause a life-threatening infection.

Kidney infection treatment, which usually includes antibiotics, might require hospitalization.

Who is more likely to develop a kidney infection ?

You are more likely to develop a kidney infection if you:

  • Are a woman 15
  • have a urinary tract infection (UTI) in the bladder.
  • had a urinary tract infection (UTI) during the past 12 months.
  • are pregnant. Scientists think that hormonal changes and shifts in the position of the urinary tract during pregnancy make it easier for bacteria to travel to the kidneys and cause infection.
  • have a problem in your urinary tract that blocks or changes the normal flow of urine. The flow of urine may be blocked if you have a defect in the structure of your urinary tract, such as a narrowed urethra, an enlarged prostate, or a kidney stone.
  • have vesicoureteral reflux, which is when urine can back up, or reflux, into one or both kidneys. Health care professionals most commonly diagnose vesicoureteral reflux in children 16.
  • have diabetes or problems with your body’s immune, or natural defense, system.
  • have a spinal cord injury or nerve damage around the bladder.
  • have trouble emptying your bladder completely, called urinary retention.

What are the complications of kidney infections ?

In rare cases, kidney infections may cause:

  • high blood pressure
  • kidney failure
  • permanent kidney scars, called renal scarring, which can lead to chronic kidney disease

Your chance of a complication is slightly greater if you have:

  • kidney disease from other causes
  • a problem with the structure of your urinary tract
  • repeated episodes of kidney infection

Complications from a kidney infection are rare if a health care professional prescribes antibiotics to treat your infection.

Kidney Cysts

Kidney cysts are round pouches of fluid that form on or in the kidneys. Kidney cysts can be associated with serious disorders that may impair kidney function 17. But more commonly, kidney cysts are a type called simple kidney cysts — noncancerous cysts that rarely cause complications.

It’s not clear what causes simple kidney cysts. Typically, only one cyst occurs on the surface of a kidney, but multiple cysts can affect one or both kidneys. However, simple kidney cysts aren’t the same as the cysts that develop when a person has polycystic kidney disease, which is a genetic disorder. Simple kidney cysts do not enlarge the kidneys, replace their normal structure, or cause reduced kidney function like cysts do in people with polycystic kidney disease.

Simple kidney cysts are often detected during an imaging test performed for another condition. Simple kidney cysts that don’t cause signs or symptoms usually don’t require treatment.

Simple kidney cysts are more common as people age. An estimated 25 percent of people 40 years of age and 50 percent of people 50 years of age have simple kidney cysts 18.

What causes simple kidney cysts ?

The cause of simple kidney cysts is not fully understood. Obstruction of tubules—tiny structures within the kidneys that collect urine—or deficiency of blood supply to the kidneys may play a role. Diverticula—sacs that form on the tubules—may detach and become simple kidney cysts. The role of genetic factors in the development of simple kidney cysts has not been studied.

What are the symptoms of simple kidney cysts ?

Simple kidney cysts usually do not cause symptoms or harm the kidneys. In some cases, however, pain can occur between the ribs and hips when cysts enlarge and press on other organs. Sometimes cysts become infected, causing fever, pain, and tenderness. Simple kidney cysts are not thought to affect kidney function, but one study found an association between the presence of cysts and reduced kidney function in hospitalized people younger than 60 years of age 18. Some studies have found a relationship between simple kidney cysts and high blood pressure. For example, high blood pressure has improved in some people after a large cyst was drained. However, this relationship is not well understood 19.

How are simple kidney cysts diagnosed ?

Most simple kidney cysts are found during imaging tests done for other reasons. When a cyst is found, the following imaging tests can be used to determine whether it is a simple kidney cyst or another, more serious condition. These imaging tests are performed at an outpatient center or hospital by a specially trained technician, and the images are interpreted by a radiologist—a doctor who specializes in medical imaging. Ultrasound may also be performed in a health care provider’s office. Anesthesia is not needed though light sedation may be used for people with a fear of confined spaces who undergo magnetic resonance imaging (MRI).

Ultrasound. Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. An abdominal ultrasound can create images of the entire urinary tract. The images can be used to distinguish harmless cysts from other problems.

Computerized tomography (CT) scan. CT scans use a combination of x-rays and computer technology to create three-dimensional (3-D) images. A CT scan may include the injection of a special dye, called contrast medium. CT scans require the person to lie on a table that slides into a tunnel-shaped device where the x-rays are taken. CT scans can show cysts and tumors in the kidneys.

Magnetic resonance imaging (MRI). MRI machines use radio waves and magnets to produce detailed pictures of the body’s internal organs and soft tissues without using x-rays. An MRI may include the injection of contrast medium. With most MRI machines, the person lies on a table that slides into a tunnel-shaped device that may be open ended or closed at one end; some newer machines are designed to allow the person to lie in a more open space. Like CT scans, MRIs can show cysts and tumors.

How are simple kidney cysts treated ?

Treatment is not needed for simple kidney cysts that do not cause any symptoms. Simple kidney cysts may be monitored with periodic ultrasounds.

Simple kidney cysts that are causing symptoms or blocking the flow of blood or urine through the kidney may need to be treated using a procedure called sclerotherapy. In sclerotherapy, the doctor punctures the cyst using a long needle inserted through the skin. Ultrasound is used to guide the needle to the cyst. The cyst is drained and then filled with a solution containing alcohol to make the kidney tissue harder. The procedure is usually performed on an outpatient basis with a local anesthetic.

If the cyst is large, surgery may be needed. Most surgeries can be performed using a laparoscope—a special tool with a small, lighted video camera. The procedure is usually done under general anesthesia in a hospital. The surgeon drains the cyst and then removes or burns away its outer tissue. This type of surgery allows for a smaller incision and quicker recovery.

Eating, Diet, and Nutrition

Eating, diet, and nutrition have not been shown to play a role in causing or preventing simple kidney cysts.

Kidney transplant

A kidney transplant is an operation that places a healthy kidney in your body. The transplanted kidney takes over the work of the two kidneys that failed, so you no longer need dialysis.

During a transplant, the surgeon places the new kidney in your lower abdomen and connects the artery and vein of the new kidney to your artery and vein. Often, the new kidney will start making urine as soon as your blood starts flowing through it. But sometimes it takes a few weeks to start working.

Many transplanted kidneys come from donors who have died. Some come from a living family member. The wait for a new kidney can be long.

On the plus side, there are fewer limits on what you can eat and drink, but you should follow a heart-healthy diet. Your health and energy should improve. In fact, a successful kidney transplant may allow you to live the kind of life you were living before you got kidney disease. Studies show that people with kidney transplants live longer than those who remain on dialysis.

On the minus side, there are the risks of surgery. And you must take anti-rejection medicines for the rest of your life, to keep your body from rejecting the new kidney, which can have side effects. You will have a higher risk for infections and certain types of cancer.

Although most transplants are successful and last for many years, how long they last can vary from one person to the next. Many people will need more than one kidney transplant during a lifetime.

What is a “preemptive” or “early” transplant ?

Getting a transplant before you need to start dialysis is called a preemptive transplant 20. It allows you to avoid dialysis altogether. Getting a transplant not long after kidneys fail (but with some time on dialysis) is referred to as an early transplant 20. Both have benefits. Some research shows that a pre-emptive or early transplant, with little or no time spent on dialysis, can lead to better long-term health. It may also allow you to keep working, save time and money, and have a better quality of life.

Who can get a kidney transplant ?

Kidney patients of all ages—from children to seniors—can get a transplant.

You must be healthy enough to have the operation. You must also be free from cancer and infection 20. Every person being considered for transplant will get a full medical and psychosocial evaluation to make sure they are a good candidate for transplant. The evaluation helps find any problems, so they can be corrected before transplant. For most people, getting a transplant can be a good treatment choice.

What if you’re older or have other health problems ?

In many cases, people who are older or have other health conditions like diabetes can still have successful kidney transplants. Careful evaluation is needed to understand and deal with any special risks. You may be asked to do some things that can lessen certain risks and improve the chances of a successful transplant. For example, you may be asked to lose weight or quit smoking.

If you have diabetes, you may also be able to have a pancreas transplant. Ask your healthcare professional about getting a pancreas transplant along with a kidney transplant.

How will you pay for a transplant ?

Medicare covers about 80% of the costs associated with an evaluation, transplant operation, follow-up care, and anti-rejection medicines. Private insurers and state programs may cover some costs as well. However, your post-transplant expenses may only be covered for a limited number of years. It’s important to discuss coverage with your social worker, who can answer your questions or direct you to others who can help.

Getting a Transplant

How do you start the process of getting a kidney transplant ?

Ask your healthcare provider to refer you to a transplant center for an evaluation, or contact a transplant center in your area. Any kidney patient can ask for an evaluation.

How does the evaluation process work ?

Medical professionals will give you a complete physical exam, review your health records, and order a series of tests and X-rays to learn about your overall health. Everything that can affect how well you can handle treatment will be checked. The evaluation process for a transplant is very thorough. Your healthcare team will need to know a lot about you to help them—and you—decide if a transplant is right for you. One thing you can do to speed the process is to get all the testing done as quickly as possible and stay in close contact with the transplant team. If you’re told you might not be right for a transplant, don’t be afraid to ask why—or if you might be eligible at some future time or at another center. Remember, being active in your own care is one of the best ways to stay healthy.

If someone you know would like to donate a kidney to you, that person will also need to go through a screening to find out if he or she is a match and healthy enough to donate.

If it’s your child who has kidney disease, you’ll want to give serious thought to getting a transplant evaluation for him or her. Because transplantation allows children and young adults to develop in as normal a way as possible in their formative years, it can be the best treatment for them.

If the evaluation process shows that a transplant is right for you or your child, the next step is getting a suitable kidney.

What does the kidney transplant operation involve ?

You may be surprised to learn that your own kidneys generally aren’t taken out when you get a transplant. The surgeon leaves them where they are unless there is a medical reason to remove them. The donated kidney is placed into your lower abdomen (belly), where it’s easiest to connect it to your important blood vessels and bladder. Putting the new kidney in your abdomen also makes it easier to take care of any problems that might come up.

The operation takes about four hours. You’ll be sore at first, but you should be out of bed in a day or so, and home within a week. If the kidney came from a living donor, it should start to work very quickly. A kidney from a deceased donor can take longer to start working—two to four weeks or more. If that happens, you may need dialysis until the kidney begins to work.

After surgery, you’ll be taught about the medicines you’ll have to take and their side effects. You’ll also learn about diet. If you’ve been on dialysis, you’ll find that there are fewer restrictions on what you can eat and drink, which is one of the benefits of a transplant.

What are anti-rejection medicines ?

Normally, your body fights off anything that isn’t part of itself, like germs and viruses. That system of protection is called your immune system. To stop your body from attacking or rejecting the donated kidney, you will have to take medicines to keep your immune system less active (called anti-rejection medicines or immunosuppressant medicines). You’ll need to take them as long as your new kidney is working. Without them, your immune system would see the donated kidney as “foreign,” and would attack and destroy it.

Anti-rejection medicines can have some side effects. It is important to talk to your healthcare provider about them, so that you know what to expect. Fortunately, for most people, side effects are usually manageable. Changing the dose or type of medicine can often ease some of the side effects.

Besides the immunosuppressive medicines, you will take other medicines as well. You will take medicines to protect you from infection, too. Most people find taking medicines a small trade for the freedom and quality of life that a successful transplant can provide.

After Your Kidney Transplant

What happens after you go home ?

Once you are home from the hospital, the most important work begins—the follow-up. For your transplant to be successful, you will have regular checkups, especially during the first year. At first, you may need blood tests several times a week. After that, you’ll need fewer checkups, but enough to make sure that your kidney is working well and that you have the right amount of anti-rejection medication in your body.

What if your body tries to reject the new kidney ?

One thing that you and your healthcare team will watch for is acute rejection, which means that your body is suddenly trying to reject the transplanted kidney. A rejection episode may not have any clear signs or symptoms. That is why it is so important to have regular blood tests to check how well your kidney is working. Things you might notice that can let you know you are having rejection are fevers, decreased urine output, swelling, weight gain, and pain over your kidney.

The chances of having a rejection episode are highest right after your surgery. The longer you have the kidney, the lower the chance that this will happen. Unfortunately, sometimes a rejection episode happens even if you’re doing everything you’re supposed to do. Sometimes the body just doesn’t accept the transplanted kidney. But even if a rejection episode happens, there are many ways to treat it so you do not lose your transplant. Letting your transplant team know right away that you think you have symptoms of rejection is very important.

How often do rejection episodes happen ?

Rejections happen much less often nowadays. That’s because there have been many improvements in immunosuppressive medicines. However, the risk of rejection is different for every person. For most people, rejection can be stopped with special anti-rejection medicines. It’s very important to have regular checkups to see how well your kidney is working, and make sure you are not having rejection.

When can you return to work ?

How soon you can return to work depends on your recovery, the kind of work you do, and your other medical conditions. Many people can return to work eight weeks or more after their transplant. Your transplant team will help you decide when you can go back to work.

Will your sex life be affected ?

People who have not had satisfactory sexual relations due to kidney disease may notice an improvement as they begin to feel better. In addition, fertility (the ability to conceive children) tends to increase. Men who have had a kidney transplant have fathered healthy children, and women with kidney transplants have had successful pregnancies. It’s best to talk to your healthcare practitioner when considering having a child.

Women should avoid becoming pregnant too soon after a transplant. Most centers want women to wait a year or more. All pregnancies must be planned. Certain medications that can harm a developing baby must be stopped six weeks before trying to get pregnant. Birth control counseling may be helpful. It’s important to protect yourself against sexually transmitted diseases (STDs). Be sure to use protection during sexual activity.

Will you need to follow a special diet ?

In general, transplant recipients should eat a heart-healthy diet (low fat, low salt) and drink plenty of fluids. If you have diabetes or other health problems, you may still have some dietary restrictions. A dietitian can help you plan meals that are right for you.

Finding a Kidney

Where do donated kidneys come from ?

A donated kidney may come from someone who died and donated a healthy kidney. A person who has died and donated a kidney is called a deceased donor.

Donated kidneys also can come from a living donor. This person may be a blood relative (like a brother or sister) or non-blood relative (like a husband or wife). They can also come from a friend or even a stranger.

When a kidney is donated by a living person, the operations are done on the same day and can be scheduled at a convenient time for both the patient and the donor. A healthy person who donates a kidney can live a normal life with the one kidney that is left. But the operation is major surgery for the donor, as well as the recipient. As in any operation, there are some risks that you will need to consider.

Is it better to get a kidney from a living donor ?

Kidneys from living or deceased donors both work well, but getting a kidney from a living donor can work faster and be better. A kidney from a living donor may last longer than one from a deceased donor.

To get a deceased donor kidney, you will be placed on a waiting list once you have been cleared for a transplant. It can take many years for a good donor kidney to be offered to you. From the time you go on the list until a kidney is found, you may have to be on some form of dialysis. While you’re waiting, you’ll need regular blood tests to make sure you are ready when a kidney is found. If you’re on dialysis, your center will make the arrangements for these tests. Your transplant center should know how to reach you at all times. Once a kidney become available, the surgery must be done as soon as possible.

Are there disadvantages to living donation ?

A disadvantage of living donation is that a healthy person must undergo surgery to remove a healthy kidney. The donor will need some recovery time before returning to work and other activities. However, recent advances in surgery (often called minimally invasive or laparoroscopic surgery) allow for very small incisions. This means shorter hospital stays and recovery time, less pain, and a quicker return to usual activities. Living donors often experience positive feelings about their courageous gift.

What are the financial costs to the living donor ?

The surgery and evaluation is covered by Medicare or the recipient’s insurance. The living donor will not pay for anything related to the surgery. However, neither Medicare nor insurance covers time off from work, travel expenses, lodging, or other incidentals. The National Living Donor Assistance Program (www.livingdonorassistance.org) or other programs may help cover travel and lodging costs.

Donors may be eligible for sick leave, state disability, and benefits under the federal Family Medical Leave Act. In addition, federal employees, some state employees, and certain other workers may be eligible for 30 days paid leave.

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  8. What is Kidney Cancer? National Kidney Foundation. https://www.kidney.org/atoz/content/what-kidney-cancer[]
  9. What Is Kidney Cancer? American Cancer Society. https://www.cancer.org/cancer/kidney-cancer/about/what-is-kidney-cancer.html[]
  10. What Are the Key Statistics About Kidney Cancer? American Cancer Society. https://www.cancer.org/cancer/kidney-cancer/about/key-statistics.html[]
  11. Chang A, Finelli A, Berns JS, Rosner M. Chronic kidney disease in patients with renal cell carcinoma. Adv Chronic Kidney Dis. Jan 2014;21(1):91-95.[]
  12. Kidney Stones. Medline Plus. https://medlineplus.gov/kidneystones.html[]
  13. Kidney infection. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/kidney-infection/symptoms-causes/syc-20353387[]
  14. Definition & Facts of Kidney Infection (Pyelonephritis). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/urologic-diseases/kidney-infection-pyelonephritis/definition-facts[]
  15. Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis of acute pyelonephritis. Clinical Infectious Diseases. 2007;45(3):273–280.[]
  16. Guarino N, Casamassima MG, Tadini B, Marras E, Lace R, Bianchi M. Natural history of vesicoureteral reflux associated with kidney anomalies. Urology. 2005;65(6):1208–1211.[]
  17. Kidney cysts. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/kidney-cysts/basics/definition/con-20035205[]
  18. Torres VE, Grantham JJ. Cystic diseases of the kidney. In: Brenner BM, ed. Brenner & Rector’s The Kidney. Vol. 2. 8th ed. Philadelphia: Saunders Elsevier; 2008: 1451–1453.[][]
  19. Zerem E, Imamovic G, Omerovic S. Simple renal cysts and arterial hypertension: does their evacuation decrease the blood pressure. Journal of Hypertension. 2009;27(10):2074–2078.[]
  20. Kidney Transplant. National Kidney Foundation. https://www.kidney.org/atoz/content/kidney-transplant[][][]
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Reproductive SystemUrinary SystemVas Deferens and Testes

Vas deferens

vasectomy

What is vas deferens

The vas deferens or the ductus deferens is a continuation of the duct of the epididymis (the spermatic cord). The term vasectomy, the surgical method of male contraception, consists of cutting out a short portion of the ductus deferens to interrupt the passage of sperm out of the testicles. Vas deferens is a muscular tube about 45 cm long and 2.5 mm in diameter. From the tail of the epididymis, it passes upward within the spermatic cord and inguinal canal and enters the pelvic cavity. There, it turns medially and approaches the urinary bladder. After passing between the bladder and ureter, the duct turns downward behind the bladder and widens into a terminal ampulla.

The vas deferens ends by uniting with the duct of the seminal vesicle. The duct has a very narrow lumen and a thick wall of smooth muscle well innervated by sympathetic nerve fibers.

The wall of the vas deferens consists of:

  • An inner mucosa with the same pseudostratified epithelium as that of the epididymis, plus a lamina propria.
  • An extremely thick muscularis. During ejaculation, the smooth muscle in the muscularis creates strong peristaltic waves that rapidly propel sperm through the ductus deferens to the urethra.
  • An outer adventitia of connective tissue.

The ejaculatory duct is about 2 cm (1 in.) long and is formed by the union of the duct from the seminal vesicle and the ampulla of the vas deferens (see Figure 2). The short ejaculatory ducts form just superior to the base (superior portion) of the prostate and pass inferiorly and anteriorly through the prostate. They  terminate in the prostatic urethra, where they eject sperm and seminal vesicle secretions just before the release of semen from the urethra to the exterior.

Figure 1. Vas deferens location

vas deferens

Figure 2. Vas deferens

vas-deferens anatomy

What is the function of the vas deferens

The ductus deferens or vas deferens, stores and transports sperm during ejaculation from the epididymis to the urethra. During ejaculation, vas deferens coordinated muscular contractions propel the spermatozoa toward the urethra. However, the vas deferens does not serve only as a conduit, but also contributes to secretion of fluid for sperm transport and possibly to resorption of spermatozoan remnants from the duct lumen 1.

Vasectomy or ‘male sterilization’ : In this minor surgery, the physician makes a small incision into both sides of the scrotum, transects both vas deferens, and then closes the cut ends, either by tying them off or by fusing them shut by cauterization. Although sperm continue to be produced, they can no longer exit the body and are phagocytized in the epididymis.

Figure 3. Vasectomy

vasectomy

Vas deferens pain

The cause of the post-vasectomy pain syndrome is unclear 2. Some postulated etiologies include epididymal congestion, tender sperm granuloma and/or nerve entrapment at the vasectomy site. Vasectomy reversal is reportedly successful for relieving pain in some patients 2.

Chronic scrotal pain

Chronic scrotal pain is defined as pain in the scrotum of more than 3-month duration, appears to be a very common condition and well recognized symptom of young males 3, 4. Chronic scrotal pain is historically defined as an intermittent or constant testicular pain, unilateral or bilateral, lasting for over 3 months that interferes significantly with the patients daily activities 5.

The probable causes of chronic scrotal pain in young men are:

  • Varicocele 54.1%
  • Idiopathic (unknown) scrotal pain 34.4%
  • Inguinal hernia 4.5%
  • Genital infections 4.3%
  • Hydrocele 4.2%
  • Referred pain 3.3%
  • Skin lesion 1.1%
  • Torsion–detorsion 0.5%
  • Trauma 0.2%
  • Kidney stone 0.1%

Varicocele was found in 54.6% of the patients and was more common among patients with longer duration of symptoms (up to 60.6%). The prevalence of varicocele in normal young men estimated at 15–20% 6 and the prevalence of pain in individuals with varicocele is estimated between approximately 2 and 10% 7, which mean estimated prevalence of painful varicocele of 0.3–2% in normal young men population.

According to Granitsiotis et al. nearly 25% of patients with chronic scrotal pain have no obvious cause for the pain 8. In another study, no specific cause could be established in 1062 patients (34.4%) 9. The percentage of patients with idiopathic scrotal pain dropped with longer symptom duration. This may suggests that in patients with idiopathic scrotal pain who complain for longer periods of time, further evaluations were done and in most cases, varicocele was found and diagnosed as the presumed cause of the symptoms.

What is varicocele ?

A varicocele is an enlargement of the veins within the loose bag of skin that holds your testicles (scrotum) 10. A varicocele is similar to a varicose vein that can occur in your leg.

Varicoceles are a common cause of low sperm production and decreased sperm quality, which can cause infertility. However, not all varicoceles affect sperm production. Varicoceles can also cause testicles to fail to develop normally or shrink.

Most varicoceles develop over time. Fortunately, most varicoceles are easy to diagnose and many don’t need treatment. If a varicocele causes symptoms, it often can be repaired surgically.

Causes of varicocele

A varicocele forms when valves inside the veins that run along the spermatic cord prevent blood from flowing properly. Blood backs up, leading to swelling and widening of the veins. (This is similar to varicose veins in the legs).

Most of the time, varicoceles develop slowly. They are more common in men ages 15 to 25 and are most often seen on the left side of the scrotum.

A varicocele in an older man that appears suddenly may be caused by a kidney tumor, which can block blood flow to a vein. The problem is more common on the left side than the right.

Symptoms of varicocele

Symptoms include:

  • Enlarged, twisted veins in the scrotum
  • Painless testicle lump, scrotal swelling, or bulge in the scrotum
  • Possible problems with fertility or decreased sperm count

Some men do not have symptoms.

How is varicocele diagnosed ?

You will have an exam of your groin area, including the scrotum and testicles. The health care provider may feel a twisted growth along the spermatic cord.

Sometimes the growth may not be able to be seen or felt, especially when you are lying down.

The testicle on the side of the varicocele may be smaller than the one on the other side.

Treatment of varicocele

A jock strap or snug underwear may help ease discomfort. You may need other treatment if the pain does not go away or you develop other symptoms.

Surgery to correct a varicocele is called varicocelectomy. For this procedure:

  • You will receive some type of numbing medicine (anesthesia).
  • The urologist will make a cut, most often in the lower abdomen, and tie off the abnormal veins. This directs blood flow in the area to the normal veins. The operation may also be done as a laparoscopic procedure (through small incisions with a camera).
  • You will be able to leave the hospital on the same day as your surgery.
  • You will need to keep an ice pack on the area for the first 24 hours after surgery to reduce swelling.

An alternative to surgery is varicocele embolization. For this procedure:

  • A small hollow tube called a catheter (tube) is placed into a vein in your groin or neck area.
  • The provider moves the tube into the varicocele using x-rays as a guide.
  • A tiny coil passes through the tube into the varicocele. The coil blocks blood flow to the bad vein and sends it to normal veins.
  • You will need to keep an ice pack on the area to reduce swelling and wear a scrotal support for a little while.

This method is also done without an overnight hospital stay. It uses a much smaller cut than surgery, so you will heal faster.

Outlook (Prognosis) for varicocele

A varicocele is often harmless and often does not need to be treated.

If you have surgery, your sperm count will likely increase. However, it will not improve your fertility. In most cases, testicular wasting (atrophy) does not improve unless surgery is done early in adolescence.

Possible Complications of varicocele

Infertility is a complication of varicocele.

Complications from treatment may include:

  • Atrophic testis
  • Blood clot formation
  • Infection
  • Injury to the scrotum or nearby blood vessel

When to Contact a Medical Professional

Call your provider if you discover a testicle lump or need to treat a diagnosed varicocele.

What is hydrocele ?

A hydrocele is a fluid-filled sac in the scrotum 11.

Causes of hydrocele

Hydroceles are common in newborn infants.

During a baby’s development in the womb, the testicles descend from the abdomen through tube into the scrotum. Hydroceles occur when this tube does not close. Fluid drains from the abdomen through the open tube and gets trapped in the scrotum. This causes the scrotum to swell.

Most hydroceles go away a few months after birth. Sometimes, a hydrocele may occur with an inguinal hernia.

Hydroceles may also be caused by:

  • Buildup of the normal fluid around the testicle. This may occur because the body makes too much of the fluid or it does not drain well. (This type of hydrocele is more common in older men.)
  • Inflammation or injury of the testicle or epididymis

Symptoms of hydrocele

The main symptom is a painless, swollen testicle, which feels like a water balloon. A hydrocele may occur on one or both sides.

How is hydrocele diagnosed ?

You will have a physical exam. The health care provider will find that the scrotum is swollen, but not painful to the touch. Often, the testicle cannot be felt because of the fluid around it. The size of the fluid-filled sac can sometimes be increased and decreased by putting pressure on the abdomen or the scrotum.

If the size of the fluid collection changes, it is more likely to be due to an inguinal hernia.

Hydroceles can be easily seen by shining a flashlight through the swollen part of the scrotum. If the scrotum is full of clear fluid, the scrotum will light up.

You may need an ultrasound to confirm the diagnosis.

Treatment for hydrocele

Hydroceles are not harmful most of the time. They are treated only when they cause infection or discomfort.

Hydroceles from an inguinal hernia should be fixed with surgery as soon as possible. Hydroceles that do not go away on their own after a few months may need surgery. A surgical procedure called a hydrocelectomy (removal of sac lining) is often done to correct the problem. Needle drainage does not work well because the fluid will come back.

Outlook (Prognosis) of hydrocele

Simple hydroceles in children often go away without surgery. In adults, hydroceles usually do not go away on their own. If surgery is needed, it is an easy procedure with very good outcomes.

Possible Complications of hydrocele

Risks from hydrocele surgery may include:

  • Blood clots
  • Infection
  • Injury to the scrotum

When to Contact a Medical Professional

Call your provider if you have symptoms of hydrocele. It is important to rule out other causes of a testicular lump.

Pain in the scrotum or testicles is an emergency. If you have pain and your scrotum is enlarged, seek medical help right away to prevent the loss of the testicle.

What is inguinal hernia ?

An inguinal hernia happens when contents of the abdomen—usually fat or part of the small intestine—bulge through a weak area in the lower abdominal wall. The abdomen is the area between the chest and the hips. The area of the lower abdominal wall is also called the inguinal or groin region.

Two types of inguinal hernias are:

  • Indirect inguinal hernias, which are caused by a defect in the abdominal wall that is congenital, or present at birth
  • Direct inguinal hernias, which usually occur only in male adults and are caused by a weakness in the muscles of the abdominal wall that develops over time

Inguinal hernias occur at the inguinal canal in the groin region.

Figure 4. Inguinal hernia

inguinal hernia

What causes inguinal hernias ?

The cause of inguinal hernias depends on the type of inguinal hernia.

Indirect inguinal hernias. A defect in the abdominal wall that is present at birth causes an indirect inguinal hernia.

During the development of the fetus in the womb, the lining of the abdominal cavity forms and extends into the inguinal canal. In males, the spermatic cord and testicles descend out from inside the abdomen and through the abdominal lining to the scrotum through the inguinal canal. Next, the abdominal lining usually closes off the entrance to the inguinal canal a few weeks before or after birth. In females, the ovaries do not descend out from inside the abdomen, and the abdominal lining usually closes a couple of months before birth 12.

Sometimes the lining of the abdomen does not close as it should, leaving an opening in the abdominal wall at the upper part of the inguinal canal. Fat or part of the small intestine may slide into the inguinal canal through this opening, causing a hernia. In females, the ovaries may also slide into the inguinal canal and cause a hernia.

Indirect hernias are the most common type of inguinal hernia 13. Indirect inguinal hernias may appear in 2 to 3 percent of male children; however, they are much less common in female children, occurring in less than 1 percent 14.

Direct inguinal hernias. Direct inguinal hernias usually occur only in male adults as aging and stress or strain weaken the abdominal muscles around the inguinal canal. Previous surgery in the lower abdomen can also weaken the abdominal muscles.

Females rarely form this type of inguinal hernia. In females, the broad ligament of the uterus acts as an additional barrier behind the muscle layer of the lower abdominal wall. The broad ligament of the uterus is a sheet of tissue that supports the uterus and other reproductive organs.

Who is more likely to develop an inguinal hernia ?

Males are much more likely to develop inguinal hernias than females. About 25 percent of males and about 2 percent of females will develop an inguinal hernia in their lifetimes.2 Some people who have an inguinal hernia on one side will have or will develop a hernia on the other side.

People of any age can develop inguinal hernias. Indirect hernias can appear before age 1 and often appear before age 30; however, they may appear later in life. Premature infants have a higher chance of developing an indirect inguinal hernia. Direct hernias, which usually only occur in male adults, are much more common in men older than age 40 because the muscles of the abdominal wall weaken with age 15.

People with a family history of inguinal hernias are more likely to develop inguinal hernias. Studies also suggest that people who smoke have an increased risk of inguinal hernias 16.

What are the signs and symptoms of an inguinal hernia ?

The first sign of an inguinal hernia is a small bulge on one or, rarely, on both sides of the groin—the area just above the groin crease between the lower abdomen and the thigh. The bulge may increase in size over time and usually disappears when lying down.

Other signs and symptoms can include:

  • discomfort or pain in the groin—especially when straining, lifting, coughing, or exercising—that improves when resting
  • feelings such as weakness, heaviness, burning, or aching in the groin
  • a swollen or an enlarged scrotum in men or boys

Indirect and direct inguinal hernias may slide in and out of the abdomen into the inguinal canal. A health care provider can often move them back into the abdomen with gentle massage.

What are the complications of inguinal hernias ?

Inguinal hernias can cause the following complications:

  • Incarceration. An incarcerated hernia happens when part of the fat or small intestine from inside the abdomen becomes stuck in the groin or scrotum and cannot go back into the abdomen. A health care provider is unable to massage the hernia back into the abdomen.
  • Strangulation. When an incarcerated hernia is not treated, the blood supply to the small intestine may become obstructed, causing “strangulation” of the small intestine. This lack of blood supply is an emergency situation and can cause the section of the intestine to die.

How are inguinal hernias treated ?

Repair of an inguinal hernia via surgery is the only treatment for inguinal hernias and can prevent incarceration and strangulation. Health care providers recommend surgery for most people with inguinal hernias and especially for people with hernias that cause symptoms. Research suggests that men with hernias that cause few or no symptoms may be able to safely delay surgery until their symptoms increase.3, 6 Men who delay surgery should watch for symptoms and see a health care provider regularly. Health care providers usually recommend surgery for infants and children to prevent incarceration.1 Emergent, or immediate, surgery is necessary for incarcerated or strangulated hernias.

A general surgeon—a doctor who specializes in abdominal surgery—performs hernia surgery at a hospital or surgery center, usually on an outpatient basis. Recovery time varies depending on the size of the hernia, the technique used, and the age and health of the person.

Hernia surgery is also called herniorrhaphy. The two main types of surgery for hernias are:

  • Open hernia repair. During an open hernia repair, a health care provider usually gives a patient local anesthesia in the abdomen with sedation; however, some patients may have
    sedation with a spinal block, in which a health care provider injects anesthetics around the nerves in the spine, making the body numb from the waist down
    general anesthesia

The surgeon makes an incision in the groin, moves the hernia back into the abdomen, and reinforces the abdominal wall with stitches. Usually the surgeon also reinforces the weak area with a synthetic mesh or “screen” to provide additional support.

  • Laparoscopic hernia repair. A surgeon performs laparoscopic hernia repair with the patient under general anesthesia. The surgeon makes several small, half-inch incisions in the lower abdomen and inserts a laparoscope—a thin tube with a tiny video camera attached. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the hernia and surrounding tissue. While watching the monitor, the surgeon repairs the hernia using synthetic mesh or “screen.”

People who undergo laparoscopic hernia repair generally experience a shorter recovery time than those who have an open hernia repair. However, the surgeon may determine that laparoscopy is not the best option if the hernia is large or if the person has had previous pelvic surgery.

Most adults experience discomfort and require pain medication after either an open hernia repair or a laparoscopic hernia repair. Intense activity and heavy lifting are restricted for several weeks. The surgeon will discuss when a person may safely return to work. Infants and children also experience some discomfort; however, they usually resume normal activities after several days.

Surgery to repair an inguinal hernia is quite safe, and complications are uncommon. People should contact their health care provider if any of the following symptoms appear:

  • redness around or drainage from the incision
  • fever
  • bleeding from the incision
  • pain that is not relieved by medication or pain that suddenly worsens

Possible long-term complications include:

  • long-lasting pain in the groin
  • recurrence of the hernia, requiring a second surgery
  • damage to nerves near the hernia

How can inguinal hernias be prevented ?

People cannot prevent the weakness in the abdominal wall that causes indirect inguinal hernias. However, people may be able to prevent direct inguinal hernias by maintaining a healthy weight and not smoking.

People can keep inguinal hernias from getting worse or keep inguinal hernias from recurring after surgery by

  • avoiding heavy lifting
  • using the legs, not the back, when lifting objects
  • preventing constipation and straining during bowel movements
  • maintaining a healthy weight
  • not smoking.
  1. Koslov DS, Andersson K-E. Physiological and pharmacological aspects of the vas deferens—an update. Frontiers in Pharmacology. 2013;4:101. doi:10.3389/fphar.2013.00101. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3749770/[]
  2. Vasectomy reversal for the post-vasectomy pain syndrome: a clinical and histological evaluation. J Urol. 2000 Dec;164(6):1939-42. https://www.ncbi.nlm.nih.gov/pubmed/11061886[][]
  3. Aljumaily A, Al-Khazraji H, Gordon A, Lau S, Jarvi KA. Characteristics and Etiologies of Chronic Scrotal Pain: A Common but Poorly Understood Condition. Pain Research & Management. 2017;2017:3829168. doi:10.1155/2017/3829168. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5352901/[]
  4. Rottenstreich M, Glick Y, Gofrit ON. Chronic scrotal pain in young adults. BMC Research Notes. 2017;10:241. doi:10.1186/s13104-017-2590-0. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496592/[]
  5. Analysis and management of chronic testicular pain. Davis BE, Noble MJ, Weigel JW, Foret JD, Mebust WK. J Urol. 1990 May; 143(5):936-9. https://www.ncbi.nlm.nih.gov/pubmed/2329609[]
  6. Evaluation of scrotal masses. Crawford P, Crop JA. Am Fam Physician. 2014 May 1; 89(9):723-7. https://www.ncbi.nlm.nih.gov/pubmed/24784335/[]
  7. Outcomes of varicocele ligation done for pain. Peterson AC, Lance RS, Ruiz HE. J Urol. 1998 May; 159(5):1565-7. https://www.ncbi.nlm.nih.gov/pubmed/9554356/[]
  8. Chronic testicular pain: an overview. Granitsiotis P, Kirk D. Eur Urol. 2004 Apr; 45(4):430-6. https://www.ncbi.nlm.nih.gov/pubmed/15041105/[]
  9. Rottenstreich M, Glick Y, Gofrit ON. Chronic scrotal pain in young adults. BMC Research Notes. 2017;10:241. doi:10.1186/s13104-017-2590-0. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496592[]
  10. Varicocele. Medline Plus. https://medlineplus.gov/ency/article/001284.htm[]
  11. Hydrocele. Medline Plus. https://medlineplus.gov/ency/article/000518.htm[]
  12. Aiken JJ, Oldham KT. Chapter 38: Inguinal hernias. In: Kleigman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia: Elsevier Saunders; 2011: 1362–1368.[]
  13. https://emedicine.medscape.com/article/189563-overview#aw2aab6b2b3[]
  14. Kelly KB, Ponsky TA. Pediatric abdominal wall defects. Surgical Clinics of North America. 2013;93(5):1255–1267.[]
  15. Quintas ML, Rodrigues CJ, Yoo JH, Rodrigues Junior AJ. Age related changes in the elastic fiber system of the interfoveolar ligament. Revista do Hospital das Clínicas. 2000;55(3):83–86.[]
  16. Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13(4):343–403.[]
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Reproductive SystemSeminal VesiclesUrinary System

Seminal vesicle

seminal vesicle

What is seminal vesicle

The seminal vesicles (seminal glands) are convoluted pouchlike structures (pair of seminal glands) posterior to the urinary bladder; one is associated with each ductus deferens. A seminal vesicle is about 5 cm long, with approximately the dimensions of one’s little finger. It has a connective tissue capsule and underlying layer of smooth muscle. The secretory portion is a very convoluted duct with numerous branches that form a complex labyrinth. It empties into the ejaculatory duct. Each ejaculatory duct is about 2 cm (1 in.) long and is formed by the union of the duct from the seminal vesicle and the ampulla of the ductus (vas) deferens. The short ejaculatory ducts form just superior to the base (superior portion) of the prostate and pass inferiorly and anteriorly through the prostate. They terminate in the prostatic urethra, where they eject sperm and seminal vesicle secretions just before the release of semen from the urethra to the exterior.

The yellowish secretion of the seminal vesicles constitutes about 60% of the semen.

Figure 1. Seminal vesicle location

seminal vesicle location

Figure 2. Seminal vesicle

seminal vesicle

What does the seminal vesicle do

The fluid expelled during orgasm is called semen (seminal fluid). A typical ejaculation discharges 2 to 5 mL of semen, composed of about 10% sperm and spermatic duct secretions, 30% prostatic fluid, 60% seminal vesicle fluid, and a trace of bulbourethral fluid. Most of the sperm emerge in the first one or two jets of semen. The semen usually has a sperm count of 50 to 120 million sperm/mL. A sperm count any lower than 20 to 25 million sperm/mL is usually associated with infertility (sterility), the inability to fertilize an egg.

The prostate and seminal vesicles contribute the following constituents to the semen:

  1. The prostate produces a thin, milky white fluid containing calcium, citrate, and phosphate ions, which is a nutrient for the sperm,; a clotting enzyme; and a protein-hydrolyzing enzyme called serine protease (prostate-specific antigen, PSA), which is an enzyme that helps liquefy semen. Measuring the levels of PSA  (prostate-specific antigen) in a man’s blood is the most important method of screening for prostate cancer
  2. The seminal vesicles contribute an alkaline viscous yellowish fluid, the last component of the semen to emerge. It contains fructose and other carbohydrates, citrate, prostaglandins and clotting proteins called prosemenogelin that are different from those in blood. The alkaline nature of the seminal
    fluid helps to neutralize the acidic environment of the male urethra and female reproductive tract that otherwise would inactivate and kill sperm. The fructose is used for ATP production by sperm. Prostaglandins contribute to sperm motility and viability and may stimulate smooth muscle contractions within the female reproductive tract. The clotting proteins help semen coagulate after ejaculation. It is thought that coagulation occurs in order to keep sperm cells from leaking from the vagina. Fluid secreted by the seminal vesicles normally constitutes about 60% of the volume of semen.

Seminal vesicle cancer

Seminal vesicle cancer (primary malignancy) are extremely rare in clinical practice 1 and only 100 such cases have been reported in the literature 2. However secondary spread is quite common either due to disseminated disease or by contiguous spread from adjacent organ, most commonly from prostate cancer 3. Most common organs from where malignancies spread to seminal vesicle are prostate, bladder and rectum. About 12% of prostate malignancy involves seminal vesicle. Bladder and rectal malignancies involve seminal vesicle only when the primary is locally advanced.

It is important to differentiate between primary and secondary spread as the former is a localized disease with possibility of cure while the later is usually an advanced disease with dismal prognosis. There is paucity of data regarding management protocols and most of the time the treatment is individualized.

Symptoms of seminal vesicle cancer can be hematospermia (blood in semen) and pain during ejaculation 1.

Types of seminal vesicle cancers

Seminal vesicle malignancies are classified as adenocarcinoma, mesenchymal tumors and mixed epithelial tumors. Adenocarcinoma is the most common primary malignant tumor of the seminal vesicle with the tumour confined to the seminal vesicle without prostatic involvement 1. Immunohistochemical studies should be negative for both PSA and prostate specific acid phosphatise 4. Mixed epithelial tumors 5 should have no normal seminal vesicle inside the tumor, without invasion of the prostate and immunohistochemical studies should be negative for both PSA and prostate specific acid phosphatase.

Operable primary seminal vesicle adenocarcinomas are treated with radical surgery – cystoprostosemino-vesiculolectomy with bilateral pelvic lymphadenectomy. Long term survival data are not available. No definite recommendations are available for adjuvant therapy, which must be individualized.

Inflammation of the seminal vesicle

Seminal vesiculitis is the seminal vesicles inflammation 6. It is a common disease of male urogenital tract. Its cause is unclear, but the lack of semenogelin I secretion is believed to be the cause of seminal vesiculitits, as it has antibacterial properties to prevent bacterial inflammation 7. Patients with seminal vesiculitis present with hematospermia (blood in semen), discomfort and pain in lumbosacral or perineal region, irritative and obstructive urinary symptoms, decreased semen volume, and/or azoospermia (absence of motile and hence viable sperm in the semen) 8. CT and MRI diagnose the complication and transurethral surgery corrected the issue 8. Transrectal ultrasonography (TRUS) can diagnosis cases of seminal vesiculitis, as well 9. Furuya et. al 10 determined that patients with urethritis are likely to have seminal vesiculitis, suggesting a close relationship between them. It is also known that epididymitis is possible along with seminal vesiculitis 11.

Seminal vesicle cyst infection

Seminal vesicle cyst infection occurs because of bacterial infection and can result in many complications. Palmer et. al 12 reported a case of patient presenting symptoms of perineal pain and fever. The patient had come in earlier with methicillin-sensitive staphylococcus aureus bacterium, and was treated with antibiotics. CT revealed an expansion of a seminal vesicle cyst, and MRI was used to confirm the diagnosis as infected cyst. Cyst was drained and it was determined that methicillin-sensitive bacterium was the cause of infection and the patient was discharged on vancomycin 12. Xu et al 13 study revealed hematospermia due to seminal vesicle cyst infection. Transvesical removal of mass was an effective surgical procedure to alleviate the disease.

Seminal vesicle abscess

Seminal vesicles abscess is a rare pathology that is rarely encountered 14. It is an infection that develops on seminal vesicles due to bacterial or viral microorganisms. Patients suffering from seminal vesicles abscess present with many uro-genital symptoms 15. Abscesses of the seminal vesicles may develop secondary to a surgical procedure due to infection. Seminal vesicles abscess may be developed secondary to vasectomy, tuberculosis, and prostate biopsy (38-41). There are different diagnostic modalities present to diagnosis seminal vesicles abscess, CT, MRI, but TRUS should be primary means of diagnosis 16. Cui et al 17 described another modality, transurethral seminal vesiculoscopy, which is used to diagnosis and treat hematospermia secondary to seminal vesicles. Drainage of abscess is the most common means of treatment 18.

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  7. Liu B, Song Z, Xu A, Su S, Wang Z, Yin C. Is abnormal expression of semenogelin I involved with seminal vesiculitis? Med Hypotheses. 2014;82:338–340. https://www.ncbi.nlm.nih.gov/pubmed/24472869[]
  8. Li YF, Liang PH, Sun ZY, Zhang Y, Bi G, Zhou B, et al. Imaging diagnosis, transurethral endoscopic observation, and management of 43 cases of persistent and refractory hematospermia. J Androl. 2012;33:906–916. https://www.ncbi.nlm.nih.gov/pubmed/22323622[][]
  9. Xu B, Li P, Niu X, Zhang X, Wang Z, Qin C, et al. A new method of chronic and recurrent seminal vesiculitis treatment. J Endourol. 2011;25:1815–1818. https://www.ncbi.nlm.nih.gov/pubmed/21870960[]
  10. Furuya R, Takahashi S, Furuya S, Saitoh N, Ogura H, Kurimura Y, et al. Is urethritis accompanied by seminal vesiculitis? Int J Urol. 2009;16:628–631. https://www.ncbi.nlm.nih.gov/pubmed/19456989[]
  11. Furuya R, Takahashi S, Furuya S, Takeyama K, Masumori N, Tsukamoto T. Chlamydial seminal vesiculitis without symptomatic urethritis and epididymitis. Int J Urol. 2006;13:466–467. https://www.ncbi.nlm.nih.gov/pubmed/16734877[]
  12. Palmer WC, Patel NC, Renew JR, Bridges MD, Stancampiano FF. Acute infection of a documented seminal vesicle cyst via hematogenous seeding. Urol J. 2013;10:1157–1159. http://www.urologyjournal.org/index.php/uj/article/view/1181/768[][]
  13. Xu LW, Cheng S, Zhang ZG, Li XD. [Transvesical removal of seminal vesicle mass: a report of 5 cases] Zhonghua Nan Ke Xue. 2009;15:357–359. https://www.ncbi.nlm.nih.gov/pubmed/19472913[]
  14. Saha S, Wright G, Arulampalam T, Corr J. An unusual groin mass. Seminal vesicle abscess: a case report. Cases Journal. 2009;2:6531. doi:10.1186/1757-1626-2-6531. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740224/[]
  15. Madrid Garcia FJ, Madronero Cuevas C, Rivas Escudero JA, Parra Muntaner L, Monsalve Rodriguez M, Garcia Alonso J. [Conservative treatment of a seminal vesicle abscess Report of one case] Arch Esp Urol. 2004;57:438–440. https://www.ncbi.nlm.nih.gov/pubmed/15270290[]
  16. Bayne CE, Davis WA, Rothstein CP, Engel JD. Seminal vesicle abscess following prostate biopsy requiring transgluteal percutaneous drainage. Can J Urol. 2013;20:6811–6814. https://www.ncbi.nlm.nih.gov/pubmed/23783054[]
  17. Cui ZQ, Wang YC, Du J, Zhou HJ, Yu ZY, Gao EJ, et al. [Transurethral seminal vesiculoscopy combined with finasteride for recurrent hematospermia] Zhonghua Nan Ke Xue. 2014;20:536–538. https://www.ncbi.nlm.nih.gov/pubmed/25029861[]
  18. Monzo JI, Lledo Garcia E, Cabello Benavente R, Moralejo Garate M, Diez Cordero JM, Hernandez Fernandez C. [Primary seminal vesicle abscess: diagnosis and treatment by transrectal ultrasound] Actas Urol Esp. 2005;29:523–525. https://www.ncbi.nlm.nih.gov/pubmed/16013801[]
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