What is a cystocele?

A cystocele, also called a prolapsed or dropped bladder, is the bulging or dropping of the bladder into the vagina. The bladder, located in the pelvis between the pelvic bones, is a hollow, muscular, balloon-shaped organ that expands as it fills with urine. During urination, also called voiding, the bladder empties through the urethra, located at the bottom of the bladder. The urethra is the tube that carries urine outside of the body. The vagina is the tube in a woman’s body that runs beside the urethra and connects the womb, or uterus, to the outside of the body.

What causes a cystocele?

A cystocele occurs when the muscles and supportive tissues between a woman’s bladder and vagina weaken and stretch, letting the bladder sag from its normal position and bulge into the vagina or through the vaginal opening. In a cystocele, the bladder tissue remains covered by the vaginal skin. A cystocele may result from damage to the muscles and tissues that hold the pelvic organs up inside the pelvis. A woman’s pelvic organs include the vagina, cervix, uterus, bladder, urethra, and small intestine. Damage to or weakening of the pelvic muscles and supportive tissues may occur after vaginal childbirth and with conditions that repeatedly strain or increase pressure in the pelvic area, such as

• repetitive straining for bowel movements
• constipation
• chronic or violent coughing
• heavy lifting
• being overweight or obese

A woman’s chances of developing a cystocele increase with age, possibly because of weakening muscles and supportive tissues from aging. Whether menopause increases a woman’s chances of developing a cystocele is unclear.

What are the symptoms of a cystocele?

The symptoms of a cystocele may include

• a vaginal bulge
• the feeling that something is falling out of the vagina
• the sensation of pelvic heaviness or fullness
• difficulty starting a urine stream
• a feeling of incomplete urination
• frequent or urgent urination

Women who have a cystocele may also leak some urine as a result of movements that put pressure on the bladder, called stress urinary incontinence. These movements can include coughing, sneezing, laughing, or physical activity, such as walking. Urinary retention—the inability to empty the bladder completely—may occur with more severe cystoceles if the cystocele creates a kink in the woman’s urethra and blocks urine flow.

Women with mild cystoceles often do not have any symptoms.

How is a cystocele diagnosed?

Diagnosing a cystocele requires medical tests and a physical exam of the vagina. Medical tests take place in a health care provider’s office, an outpatient center, or a hospital. The health care provider will ask about symptoms and medical history. A health care provider uses a grading system to determine the severity of a woman’s cystocele. A cystocele receives one of three grades depending on how far a woman’s bladder has dropped into her vagina:

• grade 1—mild, when the bladder drops only a short way into the vagina
• grade 2—moderate, when the bladder drops far enough to reach the opening of the vagina
• grade 3—most advanced, when the bladder bulges out through the opening of the vagina

If a woman has difficulty emptying her bladder, a health care provider may measure the amount of urine left in the woman’s bladder after she urinates. The remaining urine is called the postvoid residual. A health care provider can measure postvoid residual with a bladder ultrasound. A bladder ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off the bladder to create an image and show the amount of remaining urine. A specially trained technician performs the procedure, and a radiologist—a doctor who specializes in medical imaging—interprets the images. A woman does not need anesthesia.

A health care provider can also use a catheter—a thin, flexible tube—to measure a woman’s postvoid residual. The health care provider inserts the catheter through the woman’s urethra into her bladder to remove and measure the amount of remaining urine after the woman has urinated. A postvoid residual of 100 mL or more is a sign that the woman is not completely emptying her bladder. A woman receives local anesthesia.

A health care provider may use a voiding cystourethrogram—an x-ray exam of the bladder—to diagnose a cystocele as well. A woman gets a voiding cystourethrogram while urinating. The x-ray images show the shape of the woman’s bladder and let the health care provider see any problems that might block normal urine flow. An x-ray technician performs a voiding cystourethrogram, and a radiologist interprets the images. A woman does not need anesthesia; however, some women may receive sedation. A health care provider may order additional tests to rule out problems in other parts of a woman’s urinary tract.

How is a cystocele treated?

Cystocele treatment depends on the severity of the cystocele and whether a woman has symptoms. If a woman’s cystocele does not bother her, a health care provider may recommend only that she avoid heavy lifting or straining, which could worsen her cystocele. If a woman has symptoms that bother her and wants treatment, the health care provider may recommend pelvic muscle exercises, a vaginal pessary, or surgery.

Pelvic floor, or Kegel, exercises involve strengthening pelvic floor muscles. Strong pelvic floor muscles more effectively hold pelvic organs in place. A woman does not need special equipment for Kegel exercises.

The exercises involve tightening and relaxing the muscles that support pelvic organs. A health care provider can help a woman learn proper technique.

More information about pelvic muscle exercises is provided in the NIDDK health topic, Kegel Exercise Tips.

A vaginal pessary is a small, silicone medical device placed in the vagina that supports the vaginal wall and holds the bladder in place. Pessaries come in a number of shapes and sizes. A health care provider has many options to choose from to find the most comfortable pessary for a woman.

A heath care provider may recommend surgery to repair the vaginal wall support and reposition the woman’s bladder to its normal position. The most common cystocele repair is an anterior vaginal repair—or anterior colporrhaphy. The surgeon makes an incision in the wall of the woman’s vagina and repairs the defect by folding over and sewing together extra supportive tissue between the vagina and bladder. The repair tightens the layers of tissue that separate the organs, creating more support for the bladder. A surgeon who specializes in the urinary tract or female reproductive system performs an anterior vaginal repair in a hospital. The woman receives either regional or general anesthesia. The woman may stay overnight in the hospital, and full recovery may take up to 4 to 6 weeks.

Eating, Diet, and Nutrition

Researchers have not found that eating, diet, and nutrition play a role in causing or preventing a cystocele.

Points to Remember

• A cystocele, also called a prolapsed or dropped bladder, is the bulging or dropping of the bladder into the vagina.
• A cystocele occurs when the muscles and supportive tissues between a woman’s bladder and vagina weaken and stretch, letting the bladder sag from its normal position and bulge into the vagina or through the vaginal opening.
• Diagnosing a cystocele requires medical tests and a physical exam of the vagina.
• Cystocele treatment depends on the severity of the cystocele and whether a woman has symptoms.

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.

What are cystoscopy and ureteroscopy?

Cystoscopy and ureteroscopy are common procedures performed by a urologist to look inside the urinary tract. A urologist is a doctor who specializes in urinary tract problems.

Cystoscopy. Cystoscopy uses a cystoscope to look inside the urethra and bladder. A cystoscope is a long, thin optical instrument with an eyepiece at one end, a rigid or flexible tube in the middle, and a tiny lens and light at the other end of the tube. By looking through the cystoscope, the urologist can see detailed images of the lining of the urethra and bladder. The urethra and bladder are part of the urinary tract.

Ureteroscopy. Ureteroscopy uses a ureteroscope to look inside the ureters and kidneys. Like a cystoscope, a ureteroscope has an eyepiece at one end, a rigid or flexible tube in the middle, and a tiny lens and light at the other end of the tube. However, a ureteroscope is longer and thinner than a cystoscope so the urologist can see detailed images of the lining of the ureters and kidneys. The ureters and kidneys are also part of the urinary tract.

What is the urinary tract and how does it work?

The urinary tract is the body’s drainage system for removing urine, which is composed of wastes and extra fluid. In order for normal urination to occur, all body parts in the urinary tract need to work together in the correct order.

Kidneys. The kidneys are two bean-shaped organs, each about the size of a fist. They are located just below the rib cage, one on each side of the spine. Every day, the kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2 quarts of urine. The kidneys work around the clock; a person does not control what they do.

Ureters. Ureters are the thin tubes of muscle—one on each side of the bladder—that carry urine from each of the kidneys to the bladder.

Bladder. The bladder, located in the pelvis between the pelvic bones, is a hollow, muscular, balloon-shaped organ that expands as it fills with urine. Although a person does not control kidney function, a person does control when the bladder empties. Bladder emptying is known as urination. The bladder stores urine until the person finds an appropriate time and place to urinate. A normal bladder acts like a reservoir and can hold 1.5 to 2 cups of urine. How often a person needs to urinate depends on how quickly the kidneys produce the urine that fills the bladder. The muscles of the bladder wall remain relaxed while the bladder fills with urine. As the bladder fills to capacity, signals sent to the brain tell a person to find a toilet soon. During urination, the bladder empties through the urethra, located at the bottom of the bladder.

Three sets of muscles work together like a dam, keeping urine in the bladder.

The first set is the muscles of the urethra itself. The area where the urethra joins the bladder is the bladder neck. The bladder neck, composed of the second set of muscles known as the internal sphincter, helps urine stay in the bladder. The third set of muscles is the pelvic floor muscles, also referred to as the external sphincter, which surround and support the urethra.

To urinate, the brain signals the muscular bladder wall to tighten, squeezing urine out of the bladder. At the same time, the brain signals the sphincters to relax. As the sphincters relax, urine exits the bladder through the urethra.

Why is a cystoscopy or ureteroscopy performed?

A urologist performs a cystoscopy or ureteroscopy to find the cause of, and sometimes treat, urinary tract problems.

Cystoscopy. A urologist performs a cystoscopy to find the cause of urinary tract problems such as

• frequent urinary tract infections (UTIs)
• hematuria—blood in the urine
• urinary frequency—urination eight or more times a day
• urinary urgency—the inability to delay urination
• urinary retention—the inability to empty the bladder completely
• urinary incontinence—the accidental loss of urine
• pain or burning before, during, or after urination
• trouble starting urination, completing urination, or both
• abnormal cells, such as cancer cells, found in a urine sample

During a cystoscopy, a urologist can see

• stones—solid pieces of material in the bladder that may have formed in the kidneys or in the bladder when substances that are normally in the urine become highly concentrated.
• abnormal tissue, polyps, tumors, or cancer in the urethra or bladder.
• stricture, a narrowing of the urethra. Stricture can be a sign of an enlarged prostate in men or of scar tissue in the urethra.

During a cystoscopy, a urologist can treat problems such as bleeding in the bladder and blockage in the urethra. A urologist may also use a cystoscopy to

• remove a stone in the bladder or urethra.
• remove or treat abnormal tissue, polyps, and some types of tumors.
• take small pieces of urethral or bladder tissue for examination with a microscope—a procedure called a biopsy.
• inject material into the wall of the urethra to treat urinary leakage.
• inject medication into the bladder to treat urinary leakage.
• obtain urine samples from the ureters.
• perform retrograde pyelography—an x-ray procedure in which a urologist injects a special dye, called contrast medium, into a ureter to the kidney to create images of urinary flow. The test can show causes of obstruction, such as kidney stones and tumors.
• remove a stent that was placed in the ureter after a ureteroscopy with biopsy or stone removal. A stent is a small, soft tube.

Ureteroscopy. In addition to the causes of urinary tract problems he or she can find with a cystoscope, a urologist performs a ureteroscopy to find the cause of urine blockage in a ureter or to evaluate other abnormalities inside the ureters or kidneys.

During a ureteroscopy, a urologist can see

• a stone in a ureter or kidney
• abnormal tissue, polyps, tumors, or cancer in a ureter or in the lining of a kidney

During a ureteroscopy, a urologist can treat problems such as urine blockage in a ureter. The urologist can also

• remove a stone from a ureter or kidney
• remove or treat abnormal tissue, polyps, and some types of tumors
• perform a biopsy of a ureter or kidney

After a ureteroscopy, the urologist may need to place a stent in a ureter to drain urine from the kidney to the bladder while swelling in the ureter goes away. The stent, which is completely inside the body, may cause some discomfort in the kidney or bladder area. The discomfort is generally mild. The stent may be left in the ureter for a few days to a week or more. The urologist may need to perform a cystoscopy to remove the stent in the ureter.

How does a patient prepare for a cystoscopy or ureteroscopy?

In many cases, a patient does not need special preparations for a cystoscopy. A health care provider may ask the patient to drink plenty of liquids before the procedure, as well as urinate immediately before the procedure.

The patient may need to give a urine sample to test for a UTI. If the patient has a UTI, the urologist may treat the infection with antibiotics before performing a cystoscopy or ureteroscopy. A health care provider will provide instructions before the cystoscopy or ureteroscopy. These instructions may include

• when to stop certain medications, such as blood thinners
• when to stop eating and drinking
• when to empty the bladder before the procedure
• arranging for a ride home after the procedure

The urologist will ask about the patient’s medical history, current prescription and over-the-counter medications, and allergies to medications, including anesthetics. The urologist will talk about which anesthetic is best for the procedure and explain what the patient can expect after the procedure.

How is a cystoscopy or ureteroscopy performed?

A urologist performs a cystoscopy or ureteroscopy during an office visit or in an outpatient center or a hospital. For some patients, the urologist will apply an anesthetic gel around the urethral opening or inject a local anesthetic into the urethra. Some patients may require sedation or general anesthesia. The urologist often gives patients sedatives and general anesthesia for a

• ureteroscopy
• cystoscopy with biopsy
• cystoscopy to inject material into the wall of the urethra
• cystoscopy to inject medication into the bladder

For sedation and general anesthesia, a nurse or technician places an intravenous (IV) needle in a vein in the arm or hand to give the medication. Sedation helps the patient relax and be comfortable. General anesthesia puts the patient into a deep sleep during the procedure. The medical staff will monitor the patient’s vital signs and try to make him or her as comfortable as possible. During both procedures, a woman will lie on her back with the knees up and spread apart. During a cystoscopy, a man can lie on his back or be in a sitting position.

After the anesthetic has taken effect, the urologist gently inserts the tip of the cystoscope or ureteroscope into the urethra and slowly glides it through the urethra and into the bladder. A sterile liquid—water or salt water, called saline—flows through the cystoscope or ureteroscope to slowly fill the bladder and stretch it so the urologist has a better view of the bladder wall. As the bladder fills with liquid, the patient may feel some discomfort and the urge to urinate. The urologist may remove some of the liquid from the bladder during the procedure. As soon as the procedure is over, the urologist may remove the liquid from the bladder or the patient may empty the bladder.

For a cystoscopy, the urologist examines the lining of the urethra as he or she passes the cystoscope into the bladder. The urologist then examines the lining of the bladder. The urologist can insert small instruments through the cystoscope to treat problems in the urethra and bladder or perform a biopsy.

For a ureteroscopy, the urologist passes the ureteroscope through the bladder and into a ureter. The urologist then examines the lining of the ureter. He or she may pass the ureteroscope all the way up into the kidney. The urologist can insert small instruments through the ureteroscope to treat problems in the ureter or kidney or perform a biopsy.

When a urologist performs a cystoscopy or a ureteroscopy to make a diagnosis, both procedures—including preparation—take 15 to 30 minutes. The time may be longer if the urologist removes a stone in the bladder or a ureter or if he or she performs a biopsy.

What can a patient expect after a cystoscopy or ureteroscopy?

After a cystoscopy or ureteroscopy, a patient may

• have a mild burning feeling when urinating
• see small amounts of blood in the urine
• have mild discomfort in the bladder area or kidney area when urinating
• need to urinate more frequently or urgently

These problems should not last more than 24 hours. The patient should tell a health care provider right away if bleeding or pain is severe or if problems last more than a day.

The health care provider may recommend that the patient

• drink 16 ounces of water each hour for 2 hours after the procedure
• take a warm bath to relieve the burning feeling
• hold a warm, damp washcloth over the urethral opening to relieve discomfort
• take an over-the-counter pain reliever

The health care provider may prescribe an antibiotic to take for 1 or 2 days to prevent an infection. A patient should report any signs of infection—including severe pain, chills, or fever—right away to the health care provider.

Most patients go home the same day as the procedure. Recovery depends on the type of anesthesia. A patient who receives only a local anesthetic can go home immediately. A patient who receives general anesthesia may have to wait 1 to 4 hours before going home. A health care provider usually asks the patient to urinate before leaving. In some cases, the patient may need to stay overnight in the hospital. A health care provider will provide discharge instructions for rest, driving, and physical activities after the procedure.

What are the risks of cystoscopy and ureteroscopy?

The risks of cystoscopy and ureteroscopy include

• UTIs
• abnormal bleeding
• abdominal pain
• a burning feeling or pain during urination
• injury to the urethra, bladder, or ureters
• urethral narrowing due to scar tissue formation
• the inability to urinate due to swelling of surrounding tissues
• complications from anesthesia

Points to Remember

• Cystoscopy and ureteroscopy are common procedures performed by a urologist to look inside the urinary tract.
• Cystoscopy uses a cystoscope to look inside the urethra and bladder.
• Ureteroscopy uses a ureteroscope to look inside the ureters and kidneys.
• A urologist performs a cystoscopy or ureteroscopy to find the cause of, and sometimes treat, urinary tract problems.
• In many cases, a patient does not need special preparations for a cystoscopy.
• A urologist performs a cystoscopy or ureteroscopy during an office visit or in an outpatient center or a hospital.
• After a cystoscopy or ureteroscopy, a patient may
  • have a mild burning feeling when urinating
  • see small amounts of blood in the urine
  • have mild discomfort in the bladder area or kidney area when urinating
  • need to urinate more frequently or urgently
• These problems should not last more than 24 hours.
• Most patients go home the same day as the procedure.

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.

What is hematuria?

Hematuria is the presence of blood in a person’s urine. The two types of hematuria are

• gross hematuria—when a person can see the blood in his or her urine
• microscopic hematuria—when a person cannot see the blood in his or her urine, yet it is seen under a microscope

What is the urinary tract?

The urinary tract is the body’s drainage system for removing wastes and extra fluid. The urinary tract includes

• two kidneys
• two ureters
• the bladder
• the urethra

The kidneys are two bean-shaped organs, each about the size of a fist. They are located just below the rib cage, one on each side of the spine. Every day, the kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2 quarts of urine, composed of wastes and extra fluid. Children produce less urine than adults. The urine flows from the kidneys to the bladder through tubes called ureters. The bladder stores urine until releasing it through urination. When the bladder empties, urine flows out of the body through a tube called the urethra at the bottom of the bladder.

What causes hematuria?

Reasons people may have blood in the urine include

• infection in the bladder, kidney, or prostate
• trauma
• vigorous exercise
• viral illness, such as hepatitis—a virus that causes liver disease and inflammation of the liver
• sexual activity
• menstruation
• endometriosis—a problem in women that occurs when the kind of tissue that normally lines the uterus grows somewhere else, such as the bladder

More serious reasons people may have hematuria include

• bladder or kidney cancer
• inflammation of the kidney, urethra, bladder, or prostate—a walnut-shaped gland in men that surrounds the urethra and helps make semen
• blood-clotting disorders, such as hemophilia
• sickle cell disease—a genetic disorder in which a person’s body makes abnormally shaped red blood cells
• polycystic kidney disease—a genetic disorder in which many cysts grow on a person’s kidneys

Who is more likely to develop hematuria?

People who are more likely to develop hematuria may

• have an enlarged prostate
• have urinary stones
• take certain medications, including blood thinners, aspirin and other pain relievers, and antibiotics
• do strenuous exercise, such as long-distance running
• have a bacterial or viral infection, such as streptococcus or hepatitis
• have a family history of kidney disease
• have a disease or condition that affects one or more organs

What are the symptoms of hematuria?

People with gross hematuria have urine that is pink, red, or brown. Even a small amount of blood in the urine can cause urine to change color. In most cases, people with gross hematuria do not have other signs and symptoms. People with gross hematuria that includes blood clots in the urine may have bladder pain or pain in the back.

How is hematuria diagnosed?

A health care professional diagnoses hematuria or the cause of the hematuria with

• a medical history
• a physical exam
• urinalysis
• additional testing

Medical History

Taking a medical history may help a health care professional diagnose the cause of hematuria. He or she will ask the patient to provide a medical history, a review of symptoms, and a list of prescription and over-the-counter medications. The health care professional will also ask about current and past medical conditions.

Physical Exam

During a physical exam, a health care professional most often taps on the abdomen and back, checking for pain or tenderness in the bladder and kidney area. A health care professional may perform a digital rectal exam on a man to look for any prostate problems. A health care professional may perform a pelvic exam on a woman to look for the source of possible red blood cells in the urine.

Digital rectal exam. A digital rectal exam is a physical exam of a man’s 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 prostate inflammation, an enlarged prostate, or prostate cancer.

Pelvic exam. A pelvic exam is a visual and physical exam of a woman’s pelvic organs. The health care professional 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 problems that may be causing blood in the urine.

Urinalysis

The health care professional can test the urine in the office using a dipstick or can send it out to a lab for analysis. Sometimes urine tests using a dipstick can be positive even though the patient has no blood in the urine, which results in a “false-positive” test. The health care professional may look for red blood cells by examining the urine under a microscope before ordering further tests.

Prior to obtaining a urine sample, the health care professional may ask a woman when she last menstruated. Sometimes blood from a woman’s menstrual period can get into her urine sample and can result in a false-positive test for hematuria. The test should be repeated after the woman stops menstruating.

Additional Testing

Sometimes, a health care professional will test the patient’s urine again. If the urine samples detect too many red blood cells, a health care professional may order additional tests:

• 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. A blood test can detect high levels of creatinine, a waste product of normal muscle breakdown, which may indicate kidney disease. Other blood tests may detect signs of autoimmune diseases, such as lupus, or other diseases, such as prostate cancer, which can cause hematuria.
• Computed tomography (CT) scan. CT scans use a combination of x-rays and computer technology to create images of the urinary tract, especially the kidneys. A health care professional may give the patient a solution to drink and an injection of contrast medium. CT scans require the patient to lie on a table that slides into a tunnel-shaped device that takes the x-rays. An x-ray technician performs the procedure in an outpatient center or a hospital, and a radiologist interprets the images. The patient does not need anesthesia. CT scans can help a doctor diagnose stones in the urinary tract, obstructions, infections, cysts, tumors, and traumatic injuries.
• Cystoscopy. Cystoscopy is a procedure that a urologist—a doctor who specializes in urinary problems—performs to see inside the patient’s bladder and urethra using a cystoscope, a tubelike instrument. The health care professional performs cystoscopy in his or her office, in an outpatient center, or in a hospital. The patient may need pain medication. A cystoscopy can detect cancer in a patient’s bladder.
• Kidney biopsy. Kidney biopsy is a procedure that involves taking a small piece of tissue from the kidney. A health care professional performs the biopsy in an outpatient center or a hospital. The health care professional will give the patient light sedation and local anesthetic. In some cases, the patient will require general anesthesia. A pathologist—a doctor who specializes in diagnosing diseases—examines the tissue in a lab. The biopsy can help diagnose if the hematuria is due to kidney disease.
• Magnetic resonance imaging (MRI). MRI is a test that takes pictures of the patient’s internal organs and soft tissues without using x-rays. A specially trained technician performs the procedure in an outpatient center or a hospital, and a radiologist interprets the images. The patient does not need anesthesia, although patients with a fear of confined spaces may receive light sedation. An MRI may include the injection of contrast medium. With most MRI machines, the patient will lie on a table that slides into a tunnel-shaped device that may be open-ended or closed at one end. Some machines allow the patient to lie in a more open space. During an MRI, the patient should remain perfectly still while the technician takes the images. During the procedure, the patient will hear loud mechanical knocking and humming noises coming from the machine. An MRI can help diagnose problems in individual internal organs, such as the bladder or kidney.

More information is provided in the NIDDK health topic, Imaging of the Urinary Tract.

How is hematuria treated?

Health care professionals treat hematuria by treating its underlying cause. If no serious condition is causing a patient’s hematuria, he or she typically does not need treatment.

Eating, Diet, and Nutrition

Researchers have not found that eating, diet, and nutrition play a role in causing or preventing hematuria.

Points to Remember

• Hematuria is the presence of blood in a person’s urine. Gross hematuria is when a person can see the blood in his or her urine, and microscopic hematuria is when a person cannot see the blood in his or her urine, yet a health care professional can see it under a microscope.
• The causes of hematuria include vigorous exercise and sexual activity, among others.
• More serious causes of hematuria include kidney or bladder cancer; inflammation of the kidney, urethra, bladder, or prostate; and polycystic kidney disease, among other causes.
• People who are more likely to develop hematuria may have a family history of kidney disease, have an enlarged prostate, or have bladder or kidney stones, among other reasons.
• People with gross hematuria have urine that is pink, red, or brown.
• Most people with microscopic hematuria do not have any symptoms.
• Taking a medical history may help a health care professional diagnose the cause of hematuria.
• Health care professionals diagnose hematuria with a urine test called urinalysis.
• If two of three urine samples detect too many red blood cells, a health care professional may order one or more additional tests.
• Health care professionals treat hematuria by treating its underlying cause.
• Researchers have not found that eating, diet, and nutrition play a role in causing or preventing hematuria.

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.

What is Peyronie’s disease?

Peyronie’s disease is a disorder in which scar tissue, called a plaque, forms in the penis—the male organ used for urination and sex. The plaque builds up inside the tissues of a thick, elastic membrane called the tunica albuginea. The most common area for the plaque is on the top or bottom of the penis. As the plaque builds up, the penis will curve or bend, which can cause painful erections. Curves in the penis can make sexual intercourse painful, difficult, or impossible. Peyronie’s disease begins with inflammation, or swelling, which can become a hard scar.

The plaque that develops in Peyronie’s disease is not the same plaque that can develop in a person’s arteries. The plaque seen in Peyronie’s disease is benign, or noncancerous, and is not a tumor. Peyronie’s disease is not contagious or caused by any known transmittable disease.

Early researchers thought Peyronie’s disease was a form of impotence, now called erectile dysfunction (ED). ED happens when a man is unable to achieve or keep an erection firm enough for sexual intercourse. Some men with Peyronie’s disease may have ED. Usually men with Peyronie’s disease are referred to a urologist—a doctor who specializes in sexual and urinary problems.

How does an erection occur?

An erection occurs when blood flow increases into the penis, making it expand and become firm. Two long chambers inside the penis, called the corpora cavernosa, contain a spongy tissue that draws blood into the chambers. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The tunica albuginea encases the corpora cavernosa. The urethra, which is the tube that carries urine and semen outside of the body, runs along the underside of the corpora cavernosa in the middle of a third chamber called the corpus spongiosum.

An erection requires a precise sequence of events:

• An erection begins with sensory or mental stimulation, or both. The stimulus may be physical contact or a sexual image or thought.
• When the brain senses a sexual urge, it sends impulses to local nerves in the penis that cause the muscles of the corpora cavernosa to relax. As a result, blood flows in through the arteries and fills the spaces in the corpora cavernosa like water filling a sponge.
• The blood creates pressure in the corpora cavernosa, making the penis expand.
• The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining the erection.
• The erection ends after climax or after the sexual urge has passed. The muscles in the penis contract to stop the inflow of blood. The veins open and the extra blood flows out of the penis and back into the body.

What causes Peyronie’s disease?

Medical experts do not know the exact cause of Peyronie’s disease. Many believe that Peyronie’s disease may be the result of

• acute injury to the penis
• chronic, or repeated, injury to the penis
• autoimmune disease—a disorder in which the body’s immune system attacks the body’s own cells and organs

Injury to the Penis

Medical experts believe that hitting or bending the penis may injure the tissues inside. A man may injure the penis during sex, athletic activity, or an accident. Injury ruptures blood vessels, which leads to bleeding and swelling inside the layers of the tunica albuginea. Swelling inside the penis will block blood flow through the layers of tissue inside the penis. When the blood can’t flow normally, clots can form and trap immune system cells. As the injury heals, the immune system cells may release substances that lead to the formation of too much scar tissue. The scar tissue builds up and forms a plaque inside the penis. The plaque reduces the elasticity of tissues and flexibility of the penis during erection, leading to curvature. The plaque may further harden because of calcification––the process in which calcium builds up in body tissue.

Autoimmune Disease

Some medical experts believe that Peyronie’s disease may be part of an autoimmune disease. Normally, the immune system is the body’s way of protecting itself from infection by identifying and destroying bacteria, viruses, and other potentially harmful foreign substances. Men who have autoimmune diseases may develop Peyronie’s disease when the immune system attacks cells in the penis. This can lead to inflammation in the penis and can cause scarring. Medical experts do not know what causes autoimmune diseases. Some of the autoimmune diseases associated with Peyronie’s disease affect connective tissues. Connective tissue is specialized tissue that supports, joins, or separates different types of tissues and organs of the body.

How common is Peyronie’s disease?

Researchers estimate that Peyronie’s disease may affect 1 to 23 percent of men between 40 and 70 years of age.¹ However, the actual occurrence of Peyronie’s disease may be higher due to men’s embarrassment and health care providers’ limited reporting.¹ The disease is rare in young men, although it has been reported in men in their 30s.¹ The chance of developing Peyronie’s disease increases with age.

Who is more likely to develop Peyronie’s disease?

The following factors may increase a man’s chance of developing Peyronie’s disease:

• vigorous sexual or nonsexual activities that cause microscopic injury to the penis
• certain connective tissue and autoimmune disorders
• a family history of Peyronie’s disease
• aging

Vigorous Sexual and Nonsexual Activities

Men whose sexual or nonsexual activities cause microscopic injury to the penis are more likely to develop Peyronie’s disease.

Connective Tissue and Autoimmune Disorders

Men who have certain connective tissue and autoimmune disorders may have a higher chance of developing Peyronie’s disease. A common example is a condition known as Dupuytren’s disease, an abnormal cordlike thickening across the palm of the hand. Dupuytren’s disease is also known as Dupuytren’s contracture. Although Dupuytren’s disease is fairly common in older men, only about 15 percent of men with Peyronie’s disease will also have Dupuytren’s disease.² Other connective tissue disorders associated with Peyronie’s disease include

• plantar fasciitis––inflammation of the plantar fascia, thick tissue on the bottom of the foot that connects the heel bone to the toes and creates the arch of the foot
• scleroderma––abnormal growth of connective tissue, causing it to get thick and hard; scleroderma can cause swelling or pain in muscles and joints

Autoimmune disorders associated with Peyronie’s disease include

• systemic lupus erythematosus––inflammation and damage to various body tissues, including the joints, skin, kidneys, heart, lungs, blood vessels, and brain
• Sjögren’s syndrome––inflammation and damage to the glands that make tears and saliva
• Behcet’s syndrome––inflammation of the blood vessels

Family History of Peyronie’s Disease

Medical experts believe that Peyronie’s disease may run in some families. For example, a man whose father or brother has Peyronie’s disease may have an increased chance of getting the disease.

Aging

The chance of getting Peyronie’s disease increases with age. Age-related changes in the elasticity of tissues in the penis may cause it to be more easily injured and less likely to heal well.

What are the signs and symptoms of Peyronie’s disease?

The signs and symptoms of Peyronie’s disease may include

• hard lumps on one or more sides of the penis
• pain during sexual intercourse or during an erection
• a curve in the penis either with or without an erection
• narrowing or shortening of the penis
• ED

Symptoms of Peyronie’s disease range from mild to severe. Symptoms may develop slowly or appear quickly. In many cases, the pain decreases over time, although the curve in the penis may remain. In milder cases, symptoms may go away without causing a permanent curve.

What are the complications of Peyronie’s disease?

Complications of Peyronie’s disease may include

• the inability to have sexual intercourse
• ED
• anxiety, or stress, about sexual abilities or the appearance of the penis
• stress on a relationship with a sexual partner
• problems fathering a child because intercourse is difficult

How is Peyronie’s disease diagnosed?

A urologist diagnoses Peyronie’s disease based on

• a medical and family history
• a physical exam
• imaging tests

Medical and Family History

Taking a medical and family history is one of the first things a urologist may do to help diagnose Peyronie’s disease. He or she will ask the man to provide a medical and family history, which may include the following questions:

• What is the man’s ability to have an erection?
• What are the problems with sexual intercourse?
• When did the symptoms begin?
• What is the family medical history?
• What medications is the man taking?
• What other symptoms is the man experiencing?
• What other medical conditions does the man have?

Physical Exam

A physical exam may help diagnose Peyronie’s disease. During a physical exam, a urologist usually examines the man’s body, including the penis.

A urologist can usually feel the plaque in the penis with or without an erection. Sometimes the urologist will need to examine the penis during an erection. The urologist will give the man an injectable medication to cause an erection.

Imaging Tests

To help pinpoint the location of the plaque buildup inside the penis, a urologist may perform

• ultrasound of the penis
• an x-ray of the penis

For both tests, a specially trained technician performs the procedure in a health care provider’s office, an outpatient center, or a hospital, and a radiologist—a doctor who specializes in medical imaging—interprets the images. The patient does not need anesthesia.

Ultrasound. Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure.

X-ray. An x-ray is a picture created by using radiation and recorded on film or on a computer. The amount of radiation used is small. The man will lie on a table or stand during the x-ray, and the technician may ask the man to change positions for additional pictures.

How is Peyronie’s disease treated?

A urologist may treat Peyronie’s disease with nonsurgical treatments or surgery.

The goal of treatment is to reduce pain and restore and maintain the ability to have intercourse. Men with small plaques, minimal penile curvature, no pain, and satisfactory sexual function may not need treatment until symptoms get worse. Peyronie’s disease often resolves on its own without treatment.

A urologist may recommend changes in a man’s lifestyle to reduce the risk of ED associated with Peyronie’s disease.

Nonsurgical Treatments

Nonsurgical treatments include medications and medical therapies.

Medications. A urologist may prescribe medications aimed at decreasing a man’s penile curvature, plaque size, and inflammation. A man may take prescribed medications to treat Peyronie’s disease orally––by mouth––or a urologist may inject medications directly into the plaque. Verapamil is one type of topical medication that a man may apply to the skin over the plaque.

• Oral medications. Oral medications may include
  • vitamin E
  • potassium para-aminobenzoate (Potaba)
  • tamoxifen
  • colchicine
  • acetyl-L-carnitine
  • pentoxifylline
• Injections. Medications injected directly into plaques may include
  • verapamil
  • interferon alpha 2b
  • steroids
  • collagenase (Xiaflex)

To date, collagenase is the first and only medication specifically approved for Peyronie’s disease.

Medical therapies. A urologist may use medical therapies to break up scar tissue and decrease plaque size and curvature. Therapies to break up scar tissue may include

• high-intensity, focused ultrasound directed at the plaque
• radiation therapy––high-energy rays, such as x-rays, aimed at the plaque
• shockwave therapy––focused, low-intensity electroshock waves directed at the plaque

A urologist may use iontophoresis––painless, low-level electric current that delivers medications through the skin over the plaque––to decrease plaque size and curvature.

A urologist may use mechanical traction and vacuum devices aimed at stretching or bending the penis to reduce curvature.

Surgery

A urologist may recommend surgery to remove plaque or help straighten the penis during an erection. Medical experts recommend surgery for long-term cases when

• symptoms have not improved
• erections, intercourse, or both are painful
• the curve or bend in the penis does not allow the man to have sexual intercourse

Some men may develop complications after surgery, and sometimes surgery does not correct the effects of Peyronie’s disease––such as shortening of the penis. Some surgical methods can cause shortening of the penis. Medical experts suggest waiting 1 year or more from the onset of symptoms before having surgery because the course of Peyronie’s disease is different in each man.

A urologist may recommend the following surgeries:

• grafting. A urologist will cut or remove the plaque and attach a patch of skin, a vein, or material made from animal organs in its place. This procedure may straighten the penis and restore some lost length from Peyronie’s disease. However, some men may experience numbness of the penis and ED after the procedure.
• plication. A urologist will remove or pinch a piece of the tunica albuginea from the side of the penis opposite the plaque, which helps to straighten the penis. This procedure is less likely to cause numbness or ED. Plication cannot restore length or girth of the penis and may cause shortening of the penis.
• device implantation. A urologist implants a device into the penis that can cause an erection and help straighten it during an erection. Penile implants may be considered if a man has both Peyronie’s disease and ED. In some cases, an implant alone will straighten the penis adequately. If the implant alone does not straighten the penis, a urologist may combine implantation with one of the other two surgeries. Once a man has an implant, he must use the device to have an erection.

A urologist performs these surgeries in a hospital.

Lifestyle Changes

A man can make healthy lifestyle changes to reduce the chance of ED associated with Peyronie’s disease by

• quitting smoking
• reducing alcohol consumption
• exercising regularly
• avoiding illegal drugs

More information is provided in the NIDDK health topic, Erectile Dysfunction.

How can Peyronie’s disease be prevented?

Researchers do not know how to prevent Peyronie’s disease.

Eating, Diet, and Nutrition

Researchers have not found that eating, diet, and nutrition play a role in causing or preventing Peyronie’s disease.

Points to Remember

• Peyronie’s disease is a disorder in which scar tissue, called a plaque, forms in the penis—the male organ used for urination and sex.
• Medical experts do not know the exact cause of Peyronie’s disease. Many believe that Peyronie’s disease may be the result of
  • acute injury to the penis
  • chronic, or repeated, injury to the penis
  • autoimmune disease—a disorder in which the body’s immune system attacks the body’s own cells and organs
• The following factors may increase a man’s chance of developing Peyronie’s disease:
  • vigorous sexual or nonsexual activities that cause microscopic injury to the penis
  • certain connective tissue and autoimmune disorders
  • a family history of Peyronie’s disease
  • aging
• The signs and symptoms of Peyronie’s disease may include
  • hard lumps on one or more sides of the penis
  • pain during sexual intercourse or during an erection
  • a curve in the penis either with or without an erection
  • narrowing or shortening of the penis
  • erectile dysfunction (ED)
• Complications of Peyronie’s disease may include
  • the inability to have sexual intercourse
  • ED
  • anxiety, or stress, about sexual abilities or the appearance of the penis
  • stress on a relationship with a sexual partner
  • problems fathering a child because intercourse is difficult
• A urologist diagnoses Peyronie’s disease based on
  • a medical and family history
  • a physical exam
  • imaging tests
• A urologist may treat Peyronie’s disease with nonsurgical treatments or surgery.
• Researchers do not know how to prevent Peyronie’s disease.

References

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.

What is perineal injury in males?

Perineal injury is an injury to the perineum, the part of the body between the anus and the genitals, or sex organs. In males, the perineum is the area between the anus and the scrotum, the external pouch of skin that holds the testicles. Injuries to the perineum can happen suddenly, as in an accident, or gradually, as the result of an activity that persistently puts pressure on the perineum. Sudden damage to the perineum is called an acute injury, while gradual damage is called a chronic injury.

Why is the perineum important?

The perineum is important because it contains blood vessels and nerves that supply the urinary tract and genitals with blood and nerve signals. The perineum lies just below a sheet of muscles called the pelvic floor muscles. Pelvic floor muscles support the bladder and bowel.

What are the complications of perineal injury?

Injury to the blood vessels, nerves, and muscles in the perineum can lead to complications such as

• bladder control problems
• sexual problems

Bladder control problems. The nerves in the perineum carry signals from the bladder to the spinal cord and brain, telling the brain when the bladder is full. Those same nerves carry signals from the brain to the bladder and pelvic floor muscles, directing those muscles to hold or release urine. Injury to those nerves can block or interfere with the signals, causing the bladder to squeeze at the wrong time or not to squeeze at all. Damage to the pelvic floor muscles can cause bladder and bowel control problems.

Sexual problems. The perineal nerves also carry signals between the genitals and the brain. Injury to those nerves can interfere with the sensations of sexual contact.

Signals from the brain direct the smooth muscles in the genitals to relax, causing greater blood flow into the penis. In men, damaged blood vessels can cause erectile dysfunction (ED), the inability to achieve or maintain an erection firm enough for sexual intercourse. An internal portion of the penis runs through the perineum and contains a section of the urethra. As a result, damage to the perineum may also injure the penis and urethra.

What are the most common causes of acute perineal injury?

Common causes of acute perineal injury in males include

• perineal surgery
• straddle injuries
• sexual abuse
• impalement

Perineal Surgery

Acute perineal injury may result from surgical procedures that require an incision in the perineum:

• A prostatectomy is the surgical removal of the prostate to treat prostate cancer. The prostate, a walnut-shaped gland in men, surrounds the urethra at the neck of the bladder and supplies fluid that goes into semen. The surgeon chooses the location for the incision based on the patient’s physical characteristics, such as size and weight, and the surgeon’s experience and preferences. In one approach, called the radical perineal prostatectomy, the surgeon makes an incision between the scrotum and the anus. In a retropubic prostatectomy, the surgeon makes the incision in the lower abdomen, just above the penis. Both approaches can damage blood vessels and nerves affecting sexual function and bladder control.
• Perineal urethroplasty is surgery to repair stricture, or narrowing, of the portion of the urethra that runs through the perineum. Without this procedure, some men would not be able to pass urine. However, the procedure does require an incision in the perineum, which can damage blood vessels or nerves.
• Colorectal or anal cancer surgery can injure the perineum by cutting through some of the muscle around the anus to remove a tumor. One approach to anal cancer surgery involves making incisions in the abdomen and the perineum.

Surgeons try to avoid procedures that damage a person’s blood vessels, perineal nerves, and muscles. However, sometimes a perineal incision may achieve the best angle to remove a life-threatening cancer.

People should discuss the risks of any planned surgery with their health care provider so they can make an informed decision and understand what to expect after the operation.

Straddle Injuries

Straddle injuries result from falls onto objects such as metal bars, pipes, or wooden rails, where the person’s legs are on either side of the object and the perineum strikes the object forcefully. These injuries include motorcycle and bike riding accidents, saddle horn injuries during horseback riding, falls on playground equipment such as monkey bars, and gymnastic accidents on an apparatus such as the parallel bars or pommel horse.

In rare situations, a blunt injury to the perineum may burst a blood vessel inside the erectile tissue of the penis, causing a persistent partial erection that can last for days to years. This condition is called high-flow priapism. If not treated, ED may result.

Sexual Abuse

Forceful and inappropriate sexual contact can result in perineal injury. When health care providers evaluate injuries in the genital area, they should consider the possibility of sexual abuse, even if the person or family members say the injury is the result of an accident such as a straddle injury. The law requires that health care providers report cases of sexual abuse that come to their attention. The person and family members should understand the health care provider may ask some uncomfortable questions about the circumstances of the injury.

Impalement

Impalement injuries may involve metal fence posts, rods, or weapons that pierce the perineum. Impalement is rare, although it may occur where moving equipment and pointed tools are in use, such as on farms or construction sites. Impalement can also occur as the result of a fall, such as from a tree or playground equipment, onto something sharp. Impalement injuries are most common in combat situations. If an impalement injury pierces the skin and muscles, the injured person needs immediate medical attention to minimize blood loss and repair the injury.

What are the most common causes of chronic perineal injury?

Chronic perineal injury most often results from a job-or sport-related practice—such as bike, motorcycle, or horseback riding—or a long-term condition such as chronic constipation.

Bike Riding

Sitting on a narrow, saddle-style bike seat—which has a protruding “nose” in the front—places far more pressure on the perineum than sitting in a regular chair. In a regular chair, the flesh and bone of the buttocks partially absorb the pressure of sitting, and the pressure occurs farther toward the back than on a bike seat. The straddling position on a narrow seat pinches the perineal blood vessels and nerves, possibly causing blood vessel and nerve damage over time. Research shows wider, noseless seats reduce perineal pressure.¹

Occasional bike riding for short periods of time may pose no risk. However, men who ride bikes several hours a week—such as competitive bicyclists, bicycle couriers, and bicycle patrol officers—have a significantly higher risk of developing mild to severe ED.² The ED may be caused by repetitive pressure on blood vessels, which constricts them and results in plaque buildup in the vessels.

Other activities that involve riding saddle-style include motorcycle and horseback riding. Researchers have studied bike riding more extensively than these other activities; however, the few studies published regarding motorcycle and horseback riding suggest motorcycle riding increases the risk of ED and urinary symptoms.³ Horseback riding appears relatively safe in terms of chronic injury,⁴ although the action of bouncing up and down, repeatedly striking the perineum, has the potential for causing damage.

Constipation

Constipation is defined as having a bowel movement fewer than three times per week. People with constipation usually have hard, dry stools that are small in size and difficult to pass. Some people with constipation need to strain to pass stools. This straining creates internal pressure that squeezes the perineum and can damage the perineal blood vessels and nerves. More information is provided in the NIDDK health topic, Constipation.

Who is most at risk for perineal injury?

Men who have perineal surgery are most likely to have an acute perineal injury. Straddle injuries are most common among people who ride motorcycles, bikes, or horses and children who use playground equipment. Impalement injuries are most common in military personnel engaged in combat. Impalement injuries can also occur in construction or farm workers.

Chronic perineal injuries are most common in people who ride bikes as part of a job or sport, or in people with constipation.

How is perineal injury evaluated?

Health care providers evaluate perineal injury based on the circumstances and severity of the injury. In general, the evaluation process includes a physical examination and one or more imaging tests.

During a physical examination, the patient lies face up with legs spread and feet in stirrups. The health care provider looks for cuts, bruises, or bleeding from the anus. The health care provider may insert a gloved, lubricated finger into the rectum to feel for internal injuries.

To look for internal injuries, the health care provider may order one or more imaging tests. Imaging is the general term for any technique used to provide pictures of bones and organs inside the body. An x-ray technician performs these procedures in an outpatient center or a hospital, and a radiologist—a doctor who specializes in medical imaging—interprets the images. The person does not need anesthesia. However, people with a fear of confined spaces may receive light sedation before a magnetic resonance imaging (MRI) test.

• Computerized tomography (CT) scans use a combination of x-rays and computer technology to create images. For a CT scan, a health care provider may give the patient a solution to drink and an injection of a special dye, called contrast medium. CT scans require the patient to lie on a table that slides into a tunnel-shaped device where an x-ray technician takes the x-rays. CT scans can show traumatic injury to the perineum.
• MRI is a test that takes 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 patient will lie on a table that slides into a tunnel-shaped device that may be open ended or closed at one end. During an MRI, the patient, although usually awake, remains perfectly still while the technician takes the images, which usually only takes a few minutes. The technician will take a sequence of images from different angles to create a detailed picture of the perineum. The patient will hear loud mechanical knocking and humming noises. MRI results can show damage to blood vessels and muscles.
• Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. Color Doppler is enhanced ultrasound technology that shows blood flowing through arteries and veins. Blood flowing through arteries appears red, while blood flowing through veins appears blue. The color Doppler is useful in showing damage to blood vessels in the perineum.

How is perineal injury treated?

Treatments for perineal injury vary with the severity and type of injury. Tears or incisions may require stitches. Traumatic or piercing injuries may require surgery to repair damaged pelvic floor muscles, blood vessels, and nerves. Treatment for these acute injuries may also include antibiotics to prevent infection. After a health care provider stabilizes an acute injury so blood loss is no longer a concern, a person may still face some long-term effects of the injury, such as bladder control and sexual function problems. A health care provider can treat high-flow priapism caused by a blunt injury to the perineum with medication, blockage of the burst blood vessel under x-ray guidance, or surgery.

In people with a chronic perineal injury, a health care provider will treat the complications of the condition. More information is provided in the NIDDK health topics:

• Erectile Dysfunction
• Urinary Incontinence in Men

More information about the lower urinary tract is provided in the NIDDK health topic, The Urinary Tract and How It Works.

How can perineal injury be prevented?

Preventing perineal injury requires being aware of and taking steps to minimize the dangers of activities such as construction work or bike riding:

• People should talk with their health care provider about the benefits and risks of perineal surgery well before the operation.
• People who play or work around moving equipment or sharp objects should wear protective gear whenever possible.
• People who ride bikes, motorcycles, or horses should find seats or saddles designed to place the most pressure on the buttocks and minimize pressure on the perineum. Many health care providers advise bike riders to use noseless bike seats and to ride in an upright position rather than lean over the handle bars. The National Institute for Occupational Safety and Health, part of the Centers for Disease Control and Prevention, recommends noseless seats for people who ride bikes as part of their job.¹
• People with constipation should talk with their health care provider about whether to take a laxative or stool softener to minimize straining during a bowel movement.

Eating, Diet, and Nutrition

To prevent constipation, a diet with 20 to 35 grams of fiber each day helps the body form soft, bulky stool that is easier to pass. High-fiber foods include beans, whole grains and bran cereals, fresh fruits, and vegetables such as asparagus, brussels sprouts, cabbage, and carrots. For people prone to constipation, limiting foods that have little or no fiber, such as ice cream, cheese, meat, and processed foods, is also important. A health care provider can give information about how changes in eating, diet, and nutrition could help with constipation.

Points to Remember

• Perineal injury is an injury to the perineum, the part of the body between the anus and the genitals, or sex organs. In males, the perineum is the area between the anus and the scrotum, the external pouch of skin that holds the testicles.
• Injury to the blood vessels, nerves, and muscles in the perineum can lead to complications such as
  • bladder control problems
  • sexual problems
• Common causes of acute perineal injury in males include
  • perineal surgery
  • straddle injuries
  • sexual abuse
  • impalement
• Chronic perineal injury most often results from a job- or sport-related practice—such as bike, motorcycle, or horseback riding—or a long-term condition such as chronic constipation.
• Traumatic or piercing injuries may require surgery to repair damaged pelvic floor muscles, blood vessels, and nerves. Treatment for these acute injuries may also include antibiotics to prevent infection.
• In people with a chronic perineal injury, a health care provider will treat the complications of the condition, such as erectile dysfunction (ED) and urinary incontinence.
• Preventing perineal injury requires being aware of and taking steps to minimize the dangers of activities such as construction work or bike riding.
• The National Institute for Occupational Safety and Health, part of the Centers for Disease Control and Prevention, recommends noseless seats for people who ride bikes as part of their job.

References

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.

What is 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.

The prostate goes through two main growth periods as a man ages. The first occurs early in puberty, when the prostate doubles in size. The second phase of growth begins around age 25 and continues during most of a man’s life. Benign prostatic hyperplasia often occurs with the second growth phase.

As the prostate enlarges, the gland presses against and pinches the urethra. The bladder wall becomes thicker. Eventually, the bladder may weaken and lose the ability to empty completely, leaving some urine in the bladder. The narrowing of the urethra and urinary retention—the inability to empty the bladder completely—cause many of the problems associated with benign prostatic hyperplasia.

What is the prostate?

The prostate is a walnut-shaped gland that is part of the male reproductive system. The main function of the prostate is to make a fluid that goes into semen. Prostate fluid is essential for a man’s fertility. The gland surrounds the urethra at the neck of the bladder. The bladder neck is the area where the urethra joins the bladder. The bladder and urethra are parts of the lower urinary tract. The prostate has two or more lobes, or sections, enclosed by an outer layer of tissue, and it is in front of the rectum, just below the bladder. The urethra is the tube that carries urine from the bladder to the outside of the body. In men, the urethra also carries semen out through the penis.

What causes benign prostatic hyperplasia?

The cause of benign prostatic hyperplasia is not well understood; however, it occurs mainly in older men. Benign prostatic hyperplasia does not develop in men whose testicles were removed before puberty. For this reason, some researchers believe factors related to aging and the testicles may cause benign prostatic hyperplasia.

Throughout their lives, men produce testosterone, a male hormone, and small amounts of estrogen, a female hormone. As men age, the amount of active testosterone in their blood decreases, which leaves a higher proportion of estrogen. Scientific studies have suggested that benign prostatic hyperplasia may occur because the higher proportion of estrogen within the prostate increases the activity of substances that promote prostate cell growth.

Another theory focuses on dihydrotestosterone (DHT), a male hormone that plays a role in prostate development and growth. Some research has indicated that even with a drop in blood testosterone levels, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage prostate cells to continue to grow. Scientists have noted that men who do not produce DHT do not develop benign prostatic hyperplasia.

How common is benign prostatic hyperplasia?

Benign prostatic hyperplasia is the most common prostate problem for men older than age 50. In 2010, as many as 14 million men in the United States had lower urinary tract symptoms suggestive of benign prostatic hyperplasia.¹ Although benign prostatic hyperplasia rarely causes symptoms before age 40, the occurrence and symptoms increase with age. Benign prostatic hyperplasia affects about 50 percent of men between the ages of 51 and 60 and up to 90 percent of men older than 80.²

Who is more likely to develop benign prostatic hyperplasia?

Men with the following factors are more likely to develop benign prostatic hyperplasia:

• age 40 years and older
• family history of benign prostatic hyperplasia
• medical conditions such as obesity, heart and circulatory disease, and type 2 diabetes
• lack of physical exercise
• erectile dysfunction

What are the symptoms of benign prostatic hyperplasia?

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia may include

• urinary frequency—urination eight or more times a day
• urinary urgency—the inability to delay urination
• trouble starting a urine stream
• a weak or an interrupted urine stream
• dribbling at the end of urination
• nocturia—frequent urination during periods of sleep
• urinary retention
• urinary incontinence—the accidental loss of urine
• pain after ejaculation or during urination
• urine that has an unusual color or smell

Symptoms of benign prostatic hyperplasia most often come from

• a blocked urethra
• a bladder that is overworked from trying to pass urine through the blockage

The size of the prostate does not always determine the severity of the blockage or symptoms. Some men with greatly enlarged prostates have little blockage and few symptoms, while other men who have minimally enlarged prostates have greater blockage and more symptoms. Less than half of all men with benign prostatic hyperplasia have lower urinary tract symptoms.³

Sometimes men may not know they have a blockage until they cannot urinate. This condition, called acute urinary retention, can result from taking over-the-counter cold or allergy medications that contain decongestants, such as pseudoephedrine and oxymetazoline. A potential side effect of these medications may prevent the bladder neck from relaxing and releasing urine. Medications that contain antihistamines, such as diphenhydramine, can weaken the contraction of bladder muscles and cause urinary retention, difficulty urinating, and painful urination. When men have partial urethra blockage, urinary retention also can occur as a result of alcohol consumption, cold temperatures, or a long period of inactivity.

What are the complications of benign prostatic hyperplasia?

The complications of benign prostatic hyperplasia may include

• 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.

How is benign prostatic hyperplasia diagnosed?

A health care provider diagnoses benign prostatic hyperplasia based on

• a personal and family medical history
• a physical exam
• medical tests

Personal and Family Medical History

Taking a personal and family medical history is one of the first things a health care provider may do to help diagnose benign prostatic hyperplasia. A health care provider may ask a man

• what symptoms are present
• when the symptoms began and how often they occur
• whether he has a history of recurrent UTIs
• what medications he takes, both prescription and over the counter
• how much liquid he typically drinks each day
• whether he consumes caffeine and alcohol
• about his general medical history, including any significant illnesses or surgeries

Physical Exam

A physical exam may help diagnose benign prostatic hyperplasia. During a physical exam, a health care provider most often

• examines a patient’s body, which can include checking for
  • discharge from the urethra
  • enlarged or tender lymph nodes in the groin
  • a swollen or tender scrotum
• taps on specific areas of the patient’s body
• performs a digital rectal exam

A digital rectal exam, or rectal exam, is a physical exam of the prostate. To perform the exam, the health care provider asks the man to bend over a table or lie on his side while holding his knees close to his chest. The health care provider slides a gloved, lubricated finger into the rectum and feels the part of the prostate that lies next to the rectum. The man may feel slight, brief discomfort during the rectal exam. A health care provider most often performs a rectal exam during an office visit, and men do not require anesthesia. The exam helps the health care provider see if the prostate is enlarged or tender or has any abnormalities that require more testing.

Many health care providers perform a rectal exam as part of a routine physical exam for men age 40 or older, whether or not they have urinary problems.

Medical Tests

A health care provider may refer men to a urologist—a doctor who specializes in urinary problems and the male reproductive system—though the health care provider most often diagnoses benign prostatic hyperplasia on the basis of symptoms and a digital rectal exam. A urologist uses medical tests to help diagnose lower urinary tract problems related to benign prostatic hyperplasia and recommend treatment. Medical tests may include

• urinalysis
• a prostate-specific antigen (PSA) blood test
• urodynamic tests
• cystoscopy
• transrectal ultrasound
• biopsy

Urinalysis. Urinalysis involves testing a urine sample. The patient collects a urine sample in a special container in a health care provider’s office or a commercial facility. A health care provider 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.

PSA blood test. A health care provider may draw blood for a PSA test during an office visit or in a commercial facility and send the sample to a lab for analysis. Prostate cells create a protein called PSA. Men who have prostate cancer may have a higher amount of PSA in their blood. However, a high PSA level does not necessarily indicate prostate cancer. In fact, benign prostatic hyperplasia, prostate infections, inflammation, aging, and normal fluctuations often cause high PSA levels. Much remains unknown about how to interpret a PSA blood test, the test’s ability to discriminate between cancer and prostate conditions such as benign prostatic hyperplasia, and the best course of action to take if the PSA level is high.

Urodynamic tests. Urodynamic tests include a variety of procedures that look at how well the bladder and urethra store and release urine. A health care provider 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 and 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

More information is provided in the NIDDK health topic, Urodynamic Testing.

Cystoscopy. Cystoscopy is a procedure that uses a tubelike instrument, called a cystoscope, to look inside the urethra and bladder. A urologist inserts the cystoscope through the opening at the tip of the penis and into the lower urinary tract. A urologist performs cystoscopy during an office visit or in an outpatient center or a hospital. The urologist will give the patient local anesthesia; however, in some cases, the patient may require sedation and regional or general anesthesia. A urologist may use cystoscopy to look for blockage or stones in the urinary tract.

More information is provided in the NIDDK health topic, Cystoscopy and Ureteroscopy.

Transrectal ultrasound. Transrectal ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. The health care provider can move the transducer to different angles to make it possible to examine different organs. A specially trained technician performs the procedure in a health care provider’s office, an outpatient center, or a hospital, and a radiologist—a doctor who specializes in medical imaging—interprets the images; the patient does not require anesthesia. Urologists most often use transrectal ultrasound to examine the prostate. In a transrectal ultrasound, the technician inserts a transducer slightly larger than a pen into the man’s rectum, next to the prostate. The ultrasound image shows the size of the prostate and any abnormalities, such as tumors. Transrectal ultrasound cannot reliably diagnose prostate cancer.

Biopsy. Biopsy is a procedure that involves taking a small piece of prostate tissue for examination with a microscope. A urologist performs the biopsy in an outpatient center or a hospital. The urologist will give the patient light sedation and local anesthetic; however, in some cases, the patient will require general anesthesia. The urologist uses imaging techniques such as ultrasound, a computerized tomography scan, or magnetic resonance imaging to guide the biopsy needle into the prostate. A pathologist—a doctor who specializes in examining tissues to diagnose diseases—examines the prostate tissue in a lab. The test can show whether prostate cancer is present.

More information is provided in the NIDDK health topic, Medical Tests for Prostate Problems.

How is benign prostatic hyperplasia treated?

Treatment options for benign prostatic hyperplasia may include

• lifestyle changes
• medications
• minimally invasive procedures
• surgery

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.

Lifestyle Changes

A health care provider may recommend lifestyle changes for men whose symptoms are mild or slightly bothersome. Lifestyle changes can include

• reducing intake of liquids, particularly before going out in public or before periods of sleep
• avoiding or reducing intake of caffeinated beverages and alcohol
• avoiding or monitoring the use of medications such as decongestants, antihistamines, antidepressants, and diuretics
• training the bladder to hold more urine for longer periods
• exercising pelvic floor muscles
• preventing or treating constipation

Medications

A health care provider or urologist may prescribe medications that stop the growth of or shrink the prostate or reduce symptoms associated with benign prostatic hyperplasia:

• alpha blockers
• phosphodiesterase-5 inhibitors
• 5-alpha reductase inhibitors
• combination medications

Alpha blockers. These medications relax the smooth muscles of the prostate and bladder neck to improve urine flow and reduce bladder blockage:

• terazosin (Hytrin)
• doxazosin (Cardura)
• tamsulosin (Flomax)
• alfuzosin (Uroxatral)
• silodosin (Rapaflo)

Phosphodiesterase-5 inhibitors. Urologists prescribe these medications mainly for erectile dysfunction. Tadalafil (Cialis) belongs to this class of medications and can reduce lower urinary tract symptoms by relaxing smooth muscles in the lower urinary tract. Researchers are working to determine the role of erectile dysfunction drugs in the long-term treatment of benign prostatic hyperplasia.

5-alpha reductase inhibitors. These medications block the production of DHT, which accumulates in the prostate and may cause prostate growth:

• finasteride (Proscar)
• dutasteride (Avodart)

These medications can prevent progression of prostate growth or actually shrink the prostate in some men. Finasteride and dutasteride act more slowly than alpha blockers and are useful for only moderately enlarged prostates.

Combination medications. Several studies, such as the Medical Therapy of Prostatic Symptoms (MTOPS) study, have shown that combining two classes of medications, instead of using just one, can more effectively improve symptoms, urinary flow, and quality of life. The combinations include

• finasteride and doxazosin
• dutasteride and tamsulosin (Jalyn), a combination of both medications that is available in a single tablet
• alpha blockers and antimuscarinics

A urologist may prescribe a combination of alpha blockers and antimuscarinics for patients with overactive bladder symptoms. Overactive bladder is a condition in which the bladder muscles contract uncontrollably and cause urinary frequency, urinary urgency, and urinary incontinence. Antimuscarinics are a class of medications that relax the bladder muscles.

Minimally Invasive Procedures

Researchers have developed a number of minimally invasive procedures that relieve benign prostatic hyperplasia symptoms when medications prove ineffective. These procedures include

• transurethral needle ablation
• transurethral microwave thermotherapy
• high-intensity focused ultrasound
• transurethral electrovaporization
• water-induced thermotherapy
• prostatic stent insertion

Minimally invasive procedures can destroy enlarged prostate tissue or widen the urethra, which can help relieve blockage and urinary retention caused by benign prostatic hyperplasia.

Urologists perform minimally invasive procedures using the transurethral method, which involves inserting a catheter—a thin, flexible tube—or cystoscope through the urethra to reach the prostate. These procedures may require local, regional, or general anesthesia. Although destroying troublesome prostate tissue relieves many benign prostatic hyperplasia symptoms, tissue destruction does not cure benign prostatic hyperplasia. A urologist will decide which procedure to perform based on the man’s symptoms and overall health.

Transurethral needle ablation. This procedure uses heat generated by radiofrequency energy to destroy prostate tissue. A urologist inserts a cystoscope through the urethra to the prostate. A urologist then inserts small needles through the end of the cystoscope into the prostate. The needles send radiofrequency energy that heats and destroys selected portions of prostate tissue. Shields protect the urethra from heat damage.

Transurethral microwave thermotherapy. This procedure uses microwaves to destroy prostate tissue. A urologist inserts a catheter through the urethra to the prostate, and a device called an antenna sends microwaves through the catheter to heat selected portions of the prostate. The temperature becomes high enough inside the prostate to destroy enlarged tissue. A cooling system protects the urinary tract from heat damage during the procedure.

High-intensity focused ultrasound. For this procedure, a urologist inserts a special ultrasound probe into the rectum, near the prostate. Ultrasound waves from the probe heat and destroy enlarged prostate tissue.

Transurethral electrovaporization. For this procedure, a urologist inserts a tubelike instrument called a resectoscope through the urethra to reach the prostate. An electrode attached to the resectoscope moves across the surface of the prostate and transmits an electric current that vaporizes prostate tissue. The vaporizing effect penetrates below the surface area being treated and seals blood vessels, which reduces the risk of bleeding.

Water-induced thermotherapy. This procedure uses heated water to destroy prostate tissue. A urologist inserts a catheter into the urethra so that a treatment balloon rests in the middle of the prostate. Heated water flows through the catheter into the treatment balloon, which heats and destroys the surrounding prostate tissue. The treatment balloon can target a specific region of the prostate, while surrounding tissues in the urethra and bladder remain protected.

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.

Surgery

For long-term treatment of benign prostatic hyperplasia, a urologist may recommend removing enlarged prostate tissue or making cuts in the prostate to widen the urethra. Urologists recommend surgery when

• medications and minimally invasive procedures are ineffective
• symptoms are particularly bothersome or severe
• complications arise

Although removing troublesome prostate tissue relieves many benign prostatic hyperplasia symptoms, tissue removal does not cure benign prostatic hyperplasia.

Surgery to remove enlarged prostate tissue includes

• transurethral resection of the prostate (TURP)
• laser surgery
• open prostatectomy
• transurethral incision of the prostate (TUIP)

A urologist performs these surgeries, except for open prostatectomy, using the transurethral method. Men who have these surgical procedures require local, regional, or general anesthesia and may need to stay in the hospital.

The urologist may prescribe antibiotics before or soon after surgery to prevent infection. Some urologists prescribe antibiotics only when an infection occurs.

Immediately after benign prostatic hyperplasia surgery, a urologist may insert a special catheter, called a Foley catheter, through the opening of the penis to drain urine from the bladder into a drainage pouch.

TURP. With TURP, a urologist inserts a resectoscope through the urethra to reach the prostate and cuts pieces of enlarged prostate tissue with a wire loop. Special fluid carries the tissue pieces into the bladder, and the urologist flushes them out at the end of the procedure. TURP is the most common surgery for benign prostatic hyperplasia and considered the gold standard for treating blockage of the urethra due to benign prostatic hyperplasia.

Laser surgery. With this surgery, a urologist uses a high-energy laser to destroy prostate tissue. The urologist uses a cystoscope to pass a laser fiber through the urethra into the prostate. The laser destroys the enlarged tissue. The risk of bleeding is lower than in TURP and TUIP because the laser seals blood vessels as it cuts through the prostate tissue. However, laser surgery may not effectively treat greatly enlarged prostates.

Open prostatectomy. In an open prostatectomy, a urologist makes an incision, or cut, through the skin to reach the prostate. The urologist can remove all or part of the prostate through the incision. This surgery is used most often when the prostate is greatly enlarged, complications occur, or the bladder is damaged and needs repair. Open prostatectomy requires general anesthesia, a longer hospital stay than other surgical procedures for benign prostatic hyperplasia, and a longer rehabilitation period. The three open prostatectomy procedures are retropubic prostatectomy, suprapubic prostatectomy, and perineal prostatectomy. The recovery period for open prostatectomy is different for each man who undergoes the procedure. However, it typically takes anywhere from 3 to 6 weeks.⁴

TUIP. A TUIP is a surgical procedure to widen the urethra. During a TUIP, the urologist inserts a cystoscope and an instrument that uses an electric current or a laser beam through the urethra to reach the prostate. The urologist widens the urethra by making a few small cuts in the prostate and in the bladder neck. Some urologists believe that TUIP gives the same relief as TURP except with less risk of side effects.

After surgery, the prostate, urethra, and surrounding tissues may be irritated and swollen, causing urinary retention. To prevent urinary retention, a urologist inserts a Foley catheter so urine can drain freely out of the bladder. A Foley catheter has a balloon on the end that the urologist inserts into the bladder. Once the balloon is inside the bladder, the urologist fills it with sterile water to keep the catheter in place. Men who undergo minimally invasive procedures may not need a Foley catheter.

The Foley catheter most often remains in place for several days. Sometimes, the Foley catheter causes recurring, painful, difficult-to-control bladder spasms the day after surgery. However, these spasms will eventually stop. A urologist may prescribe medications to relax bladder muscles and prevent bladder spasms. These medications include

• oxybutynin chloride (Ditropan)
• solifenacin (VESIcare)
• darifenacin (Enablex)
• tolterodine (Detrol)
• hyoscyamine (Levsin)
• propantheline bromide (Pro-Banthine)

What are the complications of benign prostatic hyperplasia treatment?

The complications of benign prostatic hyperplasia treatment depend on the type of treatment.

Medications

Medications used to treat benign prostatic hyperplasia may have side effects that sometimes can be serious. Men who are prescribed medications to treat benign prostatic hyperplasia should discuss possible side effects with a health care provider before taking the medications. Men who experience the following side effects should contact a health care provider right away or get emergency medical care:

• hives
• rash
• itching
• shortness of breath
• rapid, pounding, or irregular heartbeat
• painful erection of the penis that lasts for hours
• swelling of the eyes, face, tongue, lips, throat, arms, hands, feet, ankles, or lower legs
• difficulty breathing or swallowing
• chest pain
• dizziness or fainting when standing up suddenly
• sudden decrease or loss of vision
• blurred vision
• sudden decrease or loss of hearing
• chest pain, dizziness, or nausea during sexual activity

These side effects are mostly related to phosphodiesterase-5 inhibitors. Side effects related to alpha blockers include

• dizziness or fainting when standing up suddenly
• decreased sexual drive
• problems with ejaculation

Minimally Invasive Procedures

Complications after minimally invasive procedures may include

• UTIs
• painful urination
• difficulty urinating
• an urgent or a frequent need to urinate
• urinary incontinence
• blood in the urine for several days after the procedure
• sexual dysfunction
• chronic prostatitis—long-lasting inflammation of the prostate
• recurring problems such as urinary retention and UTIs

Most of the complications of minimally invasive procedures go away within a few days or weeks. Minimally invasive procedures are less likely to have complications than surgery.

Surgery

Complications after surgery may include

• problems urinating
• urinary incontinence
• bleeding and blood clots
• infection
• scar tissue
• sexual dysfunction
• recurring problems such as urinary retention and UTIs

Problems urinating. Men may initially have painful urination or difficulty urinating. They may experience urinary frequency, urgency, or retention. These problems will gradually lessen and, after a couple of months, urination will be easier and less frequent.

Urinary incontinence. As the bladder returns to normal, men may have some temporary problems controlling urination. However, long-term urinary incontinence rarely occurs. The longer urinary problems existed before surgery, the longer it takes for the bladder to regain its full function after surgery.

Bleeding and blood clots. After benign prostatic hyperplasia surgery, the prostate or tissues around it may bleed. Blood or blood clots may appear in urine. Some bleeding is normal and should clear up within several days. However, men should contact a health care provider right away if

• they experience pain or discomfort
• their urine contains large clots
• their urine is so red it is difficult to see through

Blood clots from benign prostatic hyperplasia surgery can pass into the bloodstream and lodge in other parts of the body—most often the legs. Men should contact a health care provider right away if they experience swelling or discomfort in their legs.

Infection. Use of a Foley catheter after benign prostatic hyperplasia surgery may increase the risk of a UTI. Anesthesia during surgery may cause urinary retention and also increase the risk of a UTI. In addition, the incision site of an open prostatectomy may become infected. A health care provider will prescribe antibiotics to treat infections.

Scar tissue. In the year after the original surgery, scar tissue sometimes forms and requires surgical treatment. Scar tissue may form in the urethra and cause it to narrow. A urologist can solve this problem during an office visit by stretching the urethra. Rarely, the opening of the bladder becomes scarred and shrinks, causing blockage. This problem may require a surgical procedure similar to TUIP.

Sexual dysfunction. Some men may experience temporary problems with sexual function after benign prostatic hyperplasia surgery. The length of time for restored sexual function depends on the type of benign prostatic hyperplasia surgery performed and how long symptoms were present before surgery. Many men have found that concerns about sexual function can interfere with sex as much as the benign prostatic hyperplasia surgery itself. Understanding the surgical procedure and talking about concerns with a health care provider before surgery often help men regain sexual function earlier. Many men find it helpful to talk with a counselor during the adjustment period after surgery. Even though it can take a while for sexual function to fully return, with time, most men can enjoy sex again.

Most health care providers agree that if men with benign prostatic hyperplasia were able to maintain an erection before surgery, they will probably be able to have erections afterward. Surgery rarely causes a loss of erectile function. However, benign prostatic hyperplasia surgery most often cannot restore function that was lost before the procedure. Some men find a slight difference in the quality of orgasm after surgery. However, most report no difference.

Prostate surgery may make men sterile, or unable to father children, by causing retrograde ejaculation—the backward flow of semen into the bladder. Men flush the semen out of the bladder when they urinate. In some cases, medications such as pseudoephedrine, found in many cold medications, or imipramine can treat retrograde ejaculation. These medications improve muscle tone at the bladder neck and keep semen from entering the bladder.

Recurring problems. Men may require further treatment if prostate problems, including benign prostatic hyperplasia, return. Problems may arise when treatments for benign prostatic hyperplasia leave a good part of the prostate intact. About 10 percent of men treated with TURP or TUIP require additional surgery within 5 years. About 2 percent of men who have an open prostatectomy require additional surgery within 5 years.²

In the years after benign prostatic hyperplasia surgery or treatment, men should continue having a digital rectal exam once a year and have any symptoms checked by a health care provider. In some cases, the health care provider may recommend a digital rectal exam and checkup more than once a year.

How can benign prostatic hyperplasia be prevented?

Researchers have not found a way to prevent benign prostatic hyperplasia. Men with risk factors for benign prostatic hyperplasia should talk with a health care provider about any lower urinary tract symptoms and the need for regular prostate exams. Men can get early treatment and minimize benign prostatic hyperplasia effects by recognizing lower urinary tract symptoms and identifying an enlarged prostate.

Eating, Diet, and Nutrition

Researchers have not found that eating, diet, and nutrition play a role in causing or preventing benign prostatic hyperplasia. However, a health care provider can give information about how changes in eating, diet, or nutrition could help with treatment. Men should talk with a health care provider or dietitian about what diet is right for them.

Points to Remember

• Benign prostatic hyperplasia—also called BPH—is a condition in men in which the prostate gland is enlarged and not cancerous.
• The prostate is a walnut-shaped gland that is part of the male reproductive system.
• The cause of benign prostatic hyperplasia is not well understood; however, it occurs mainly in older men.
• Benign prostatic hyperplasia is the most common prostate problem for men older than age 50.
• Lower urinary tract symptoms suggestive of benign prostatic hyperplasia may include
  • urinary frequency—urination eight or more times a day
  • urinary urgency—the inability to delay urination
  • trouble starting a urine stream
  • a weak or an interrupted urine stream
  • dribbling at the end of urination
  • nocturia—frequent urination during periods of sleep
  • urinary retention—the inability to empty the bladder completely
  • urinary incontinence—the accidental loss of urine
  • pain after ejaculation or during urination
  • urine that has an unusual color or smell
• The complications of benign prostatic hyperplasia may include
  • acute urinary retention
  • chronic, or long lasting, urinary retention
  • blood in the urine
  • urinary tract infections (UTIs)
  • bladder damage
  • kidney damage
  • bladder stones
• A health care provider diagnoses benign prostatic hyperplasia based on
  • a personal and family medical history
  • a physical exam
  • medical tests
• Treatment options for benign prostatic hyperplasia may include
  • lifestyle changes
  • medications
  • minimally invasive procedures
  • surgery
• The complications of benign prostatic hyperplasia treatment depend on the type of treatment.
• Researchers have not found a way to prevent benign prostatic hyperplasia.
• Researchers have not found that eating, diet, and nutrition play a role in causing or preventing benign prostatic hyperplasia.

References

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.

What is the prostate?

The prostate is a walnut-shaped gland that is part of the male reproductive system. It has two or more lobes, or sections, enclosed by an outer layer of tissue. The prostate is located in front of the rectum and just below the bladder, where urine is stored. It surrounds the urethra at the neck of the bladder and supplies fluid that goes into semen.

What are some common prostate problems?

The most common prostate problem in men younger than age 50 is inflammation, called prostatitis. Prostate enlargement, or benign prostatic hyperplasia (BPH), is another common problem. Because the prostate continues to grow as a man ages, BPH is the most common prostate problem for men older than age 50. Older men are at risk for prostate cancer as well, but it is much less common than BPH.

What are the symptoms of prostate problems?

The symptoms of prostate problems may include

• urinary retention—the inability to empty the bladder completely
• urinary frequency—urination eight or more times a day
• urinary urgency—the inability to delay urination
• urinary incontinence—the accidental loss of urine
• nocturia—frequent urination at night
• trouble beginning a urine stream
• weak or interrupted urine stream
• blockage of urine
• urine that has an unusual color or odor
• pain after ejaculation or during urination

Different prostate problems may have similar symptoms. For example, one man with prostatitis and another with BPH may both experience urinary urgency. Sometimes symptoms for the same prostate problem differ among individuals. For example, one man with BPH may have trouble beginning a urine stream, while another may experience nocturia. A man in the early stages of prostate cancer may have no symptoms at all. Because of this confusing array of symptoms, a thorough medical exam and testing are vital.

How are prostate problems diagnosed?

To diagnose prostate problems, the health care provider will perform a digital rectal exam (DRE). The health care provider will also ask the patient

• when the problem began and how often it occurs
• what symptoms are present
• whether he has a history of recurrent urinary tract infections
• what medications he takes, both prescription and those bought over the counter
• the amount of fluid he typically drinks each day
• whether he consumes caffeine and alcohol
• about his general medical history, including any major illnesses or surgeries

Answers to these questions will help the health care provider identify the problem or determine what medical tests are needed. Diagnosing BPH may require a series of medical exams and tests.

How is a digital rectal exam (DRE) performed?

A DRE is a physical exam of the prostate. The health care provider will ask the patient to bend over a table or lie on his side while holding his knees close to his chest. The health care provider slides a gloved, lubricated finger into the rectum and feels the part of the prostate that lies next to it. The DRE may be slightly uncomfortable, but it is brief. This exam reveals whether the prostate has any abnormalities that require more testing. If an infection is suspected, the health care provider might massage the prostate during the DRE to obtain fluid to examine with a microscope. This exam is usually done first. Many health care providers perform a DRE as part of a routine physical exam for men age 50 or older, some even at age 40, whether or not the man has urinary problems.

What is the first test for detecting prostate problems?

The first test for detecting prostate problems is a blood test to measure prostate-specific antigen (PSA), a protein made only by the prostate gland. This test is often included in routine physical exams for men older than age 50. Because African American men have higher rates of getting, and dying from, prostate cancer than men of other racial or ethnic groups in the United States, medical organizations recommend a PSA blood test be given starting at age 40 for African American men. Medical organizations also recommend a PSA blood test be given starting at age 40 for men with a family history of prostate cancer. Some medical organizations even recommend a PSA blood test be given to all men starting at age 40.

If urination problems are present or if a PSA blood test indicates a problem, additional tests may be ordered. These tests may require a patient to change his diet or fluid intake or to stop taking medications. If the tests involve inserting instruments into the urethra or rectum, antibiotics may be given before and after the test to prevent infection.

Why is a prostate-specific antigen (PSA) blood test performed?

A PSA blood test is performed to detect or rule out prostate cancer. The amount of PSA in the blood is often higher in men who have prostate cancer. However, an elevated PSA level does not necessarily indicate prostate cancer. The U.S. Food and Drug Administration has approved the PSA blood test for use in conjunction with a DRE to help detect prostate cancer in men age 50 or older and for monitoring men with prostate cancer after treatment. However, much remains unknown about how to interpret a PSA blood test, its ability to discriminate between cancer and problems such as BPH and prostatitis, and the best course of action if the PSA level is high.

When done in addition to a DRE, a PSA blood test enhances detection of prostate cancer. However, the test is known to have relatively high false-positive rates. A PSA blood test also may identify a greater number of medically insignificant lumps or growths, called tumors, in the prostate. Health care providers and patients should weigh the benefits of PSA blood testing against the risks of follow-up diagnostic tests. The procedures used to diagnose prostate cancer may cause significant side effects, including bleeding and infection.

What are additional tests for detecting prostate problems?

If the DRE or the PSA blood test indicates a problem may exist, the health care provider may order additional tests, including urinalysis, urodynamic tests, cystoscopy, abdominal ultrasound, transrectal ultrasound with prostate biopsy, and imaging studies such as magnetic resonance imaging (MRI) or computerized tomography (CT) scan.

Urinalysis

Urinalysis is the testing of a urine sample for abnormal substances or signs of infection. The urine sample is collected in a special container in a health care provider’s office or commercial facility and can be tested in the same location or sent to a lab for analysis.

If an infection is suspected, the health care provider may ask that the urine sample be collected in two or three containers during a single urination to help locate the infection site. After the first collection, the health care provider will have the patient stop the urine stream for a prostate massage before collecting more urine. If signs of infection appear in the first container but not in the others, the infection is likely to be in the urethra. If the urine contains significantly more bacteria after the prostate massage or bacteria are in the prostate fluid itself, the infection is likely to be in the prostate.

Urodynamic Tests

Urodynamic testing is any procedure that looks at how well the bladder, sphincters, and urethra are storing and releasing urine. Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely. If the prostate problem appears to be related to urine blockage, the health care provider may recommend tests that measure bladder pressure and urine flow rate. One test involves urinating into a special device that measures how quickly the urine is flowing and records how many seconds it takes for the peak flow rate to be reached. Another test measures postvoid residual, the amount of urine left in the bladder when urination stops. A weak urine stream and urinary retention may be signs of urine blockage caused by an enlarged prostate that is squeezing the urethra. Some urodynamic tests are performed in a health care provider’s office without anesthesia. Other urodynamic tests are performed in a health care provider’s office, outpatient center, or hospital with local anesthesia.

Cystoscopy

Cystoscopy is a procedure that allows the health care provider to look for blockage in the lower urinary tract. A cystoscope is a tubelike instrument used to look inside the urethra and bladder. After a solution numbs the inside of the penis, the health care provider inserts the cystoscope through the opening at the tip of the penis and into the lower urinary tract. By looking through the cystoscope, the health care provider can determine the location and degree of the urine blockage. A cystoscopy is performed in a health care provider’s office, outpatient center, or hospital with local anesthesia. The procedure is usually performed by a urologist, a doctor who specializes in treating problems of the urinary tract and the male reproductive system.

Abdominal Ultrasound

Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. The transducer can be moved to different angles to make it possible to examine different organs. In abdominal ultrasound, the health care provider applies a gel to the patient’s abdomen and moves a handheld transducer over the skin. The gel allows the transducer to glide easily, and it improves the transmission of the signals. The procedure is performed in a health care provider’s office, outpatient center, or hospital by a specially trained technician and interpreted by a doctor, usually a radiologist—a doctor who specializes in medical imaging. Anesthesia is not needed. An abdominal ultrasound can create images of the entire urinary tract. The images can show damage or abnormalities in the urinary tract resulting from urine blockage at the prostate.

Transrectal Ultrasound with Prostate Biopsy

Transrectal ultrasound is most often used to examine the prostate. In a transrectal ultrasound, the health care provider inserts a transducer slightly larger than a pen into the man’s rectum next to the prostate. The ultrasound image shows the size of the prostate and any abnormal-looking areas, such as tumors. Transrectal ultrasound cannot definitively identify prostate cancer.

To determine whether a tumor is cancerous, the health care provider uses the transducer and ultrasound images to guide a needle to the tumor. The needle is then used to remove a few pieces of prostate tissue for examination with a microscope. This process, called biopsy, can reveal whether prostate cancer is present. A transrectal ultrasound with prostate biopsy is usually performed by a doctor in a health care provider’s office, outpatient center, or hospital with light sedation and local anesthesia. The biopsied prostate tissue is examined in a laboratory by a pathologist—a doctor who specializes in diagnosing diseases.

MRI and CT Scan

An MRI is a test that takes pictures of the body’s internal organs and soft tissues without using x-rays. The MRI machines use radio waves and magnets to produce detailed pictures. An MRI may also involve the injection of dye. A CT scan uses a combination of x-rays and computer technology to create three-dimensional (3-D) images. A CT scan may also involve the injection of a dye. MRI and CT scan images can help identify abnormal structures in the urinary tract, but they cannot distinguish between cancerous tumors and noncancerous prostate enlargement. Once a biopsy has confirmed cancer, these imaging techniques will show how far the cancer has spread. MRIs and CT scans are usually performed at an outpatient center or hospital by a specially trained technician and interpreted by a radiologist; anesthesia is not needed. For an MRI, light sedation may be used for people with a fear of confined spaces.

What happens after the prostate tests?

Urodynamic tests and cystoscopy may cause mild discomfort for a few hours after the procedures. Drinking an 8-ounce glass of water every half-hour for 2 hours may help reduce discomfort. The health care provider may recommend taking a warm bath or holding a warm, damp washcloth over the urethral opening to relieve discomfort. A prostate biopsy may produce pain in the area of the rectum and the perineum, which is between the rectum and the scrotum. A prostate biopsy may also produce blood in urine and semen.

An antibiotic may be prescribed for 1 or 2 days to prevent infection. Patients with signs of infection—including pain, chills, or fever—should call their health care provider immediately.

How soon will prostate test results be available?

Results for simple medical tests such as some urodynamic tests, cystoscopy, and abdominal ultrasound are often available soon after the test. The results of other medical tests such as PSA blood test and prostate tissue biopsy may take several days to come back. A health care provider will talk with the patient about the results and possible treatments for the problem.

Eating, Diet, and Nutrition

Eating, diet, and nutrition have not been shown to play a role in causing or preventing prostate problems.

Points to Remember

• Common prostate problems are prostatitis and benign prostatic hyperplasia (BPH).
• Prostatitis is the most common prostate problem for men younger than age 50.
• BPH is the most common prostate problem for men older than age 50.
• Older men are at risk for prostate cancer, but it is much less common than BPH.
• Because different prostate problems have similar symptoms, diagnosing the problem may require a series of medical exams and tests.
• Medical tests to detect prostate problems include prostate-specific antigen (PSA) blood test, urinalysis, urodynamic tests, cystoscopy, and abdominal ultrasound.
• If prostate cancer is suspected, transrectal ultrasound with prostate biopsy is performed.
• Some medical tests require no preparation, while others may require changes in diet and fluid intake or a stop of medications.
• Some medical tests may be slightly uncomfortable. Others cause mild discomfort for a few hours after the procedure.
• Some medical test results are available soon after the test, while other medical test results may take several days to come back.

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.

What is urinary diversion?

Urinary diversion is a surgical procedure that reroutes the normal flow of urine out of the body when urine flow is blocked. Urine flow may be blocked because of

• an enlarged prostate
• injury to the urethra
• birth defects of the urinary tract
• kidney, ureter, or bladder stones
• tumors of the genitourinary tract—which includes the urinary tract and reproductive organs—or adjacent tissues and organs
• conditions causing external pressure to the urethra or one or both ureters

Bladder removal or a malfunctioning bladder may also cause blocked urine flow. When urine cannot flow out of the body, it can accumulate in the bladder, ureters, and kidneys. As a result, body wastes and extra water do not empty from the body, potentially resulting in pain, urinary tract infections, kidney failure, or, if left untreated, death. Urinary diversion can be temporary or permanent, depending on the reason for the procedure.

What is the urinary tract and how does it work?

The urinary tract is the body’s drainage system for removing urine, which is composed of wastes and extra fluid. In order for normal urination to occur, all body parts in the urinary tract need to work together in the correct order.

Kidneys. The kidneys are two bean-shaped organs, each about the size of a fist. They are located just below the rib cage, one on each side of the spine. Every day, the kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2 quarts of urine. The kidneys work around the clock; a person does not control what they do.

Ureters. Ureters are the thin tubes of muscle—one on each side of the bladder—that carry urine from each of the kidneys to the bladder.

Bladder. The bladder, located in the pelvis between the pelvic bones, is a hollow, muscular, balloon-shaped organ that expands as it fills with urine. Although a person does not control kidney function, a person does control when the bladder empties. Bladder emptying is known as urination. The bladder stores urine until the person finds an appropriate time and place to urinate. A normal bladder acts like a reservoir and can hold 1.5 to 2 cups of urine. How often a person needs to urinate depends on how quickly the kidneys produce the urine that fills the bladder. The muscles of the bladder wall remain relaxed while the bladder fills with urine. As the bladder fills to capacity, signals sent to the brain tell a person to find a toilet soon.

Three sets of muscles work together like a dam, keeping urine in the bladder:

During urination, the bladder empties through the urethra, located at the bottom of the bladder. The urethra is the tube that carries urine outside of the body. The urethra is made up of muscles that stay closed while the bladder fills with urine. The area where the urethra joins the bladder is the bladder neck. The bladder neck is composed of muscles known as the internal sphincter. The urethra is surrounded by muscles called the pelvic floor muscles, also referred to as the external sphincter.

To urinate, the brain signals the muscular bladder wall to tighten, squeezing urine out of the bladder. At the same time, the brain signals the sphincters to relax. As the sphincters relax, urine exits the bladder through the urethra.

What is temporary urinary diversion?

Temporary urinary diversion reroutes the flow of urine for several days or weeks. Temporary urinary diversions drain urine until the cause of blockage is treated or after urinary tract surgery. This type of urinary diversion includes a nephrostomy and urinary catheterization.

What is a nephrostomy?

A nephrostomy involves a small tube inserted through the skin directly into a kidney. The nephrostomy tube drains urine from the kidney into an external drainage pouch. Nephrostomy tubes are often used for less than a week after a percutaneous nephrolithotomy—a surgical procedure to break up and remove a kidney stone.

This treatment is often used when a kidney stone is quite large or in a location that does not permit effective use of other treatments. For this procedure, a surgeon makes a tiny incision in the back and creates a tunnel into one of the kidneys. As the kidney heals after surgery, the nephrostomy provides an alternative route for urine drainage until normal urinary flow resumes. A person may also need a nephrostomy if narrowing, blockage, or inflammation of the ureters keeps urine from draining properly. Under these circumstances, the nephrostomy may stay in place for several weeks until the problem is resolved.

What is urinary catheterization?

Urinary catheterization involves placing a thin, flexible tube—called a catheter—into the bladder to drain urine. Two methods of urinary catheterization include insertion of a catheter through the urethra or through an incision in the skin. For the first method, a special type of catheter, called a Foley catheter, is inserted through the urethra. A Foley catheter has a water-filled balloon on the end that a health care provider inserts into the bladder to keep the catheter in place. For the second method, called a suprapubic catheterization, a catheter is inserted through an incision in the skin beneath the belly button directly into the bladder. Urinary catheters may remain in place for several days or weeks while tissues heal after urinary tract surgery or treatment of urinary blockage.

What is permanent urinary diversion?

Permanent urinary diversion requires surgery to reroute urine flow to an external pouch through an opening in the wall of the abdomen, called a stoma, or to a surgically created internal reservoir. Stomas range from three-fourths of an inch to 3 inches wide. Surgeons perform permanent urinary diversion when a patient has a damaged bladder or no longer has a bladder. Advanced bladder cancer ranks as the most common reason for bladder removals. Bladder damage may result from nerve damage, birth defects, or chronic—or long lasting—inflammation. Nerve damage severe enough to require permanent urinary diversion generally occurs from multiple sclerosis, among other diseases; spinal cord injuries; and damage caused by pelvic trauma or radiation injury. The most common birth defect requiring bladder surgery is spina bifida. Chronic bladder inflammation can result from severe cases of interstitial cystitis or chronic urinary retention. Interstitial cystitis is a condition that causes the bladder to become swollen and irritated, leading to decreased bladder capacity. Urinary retention is the inability to empty the bladder completely.

More information is provided in the NIDDK health topics:

• Interstitial Cystitis
• Urinary Retention

The two permanent types of urinary diversion include urostomy and continent urinary diversion. A urostomy, also called a noncontinent urinary diversion, requires an external pouch—a disposable plastic bag that sticks to the skin of the abdomen. A continent urinary diversion involves the creation of an internal reservoir with a segment of bowel—also called the small and large intestines—that stores urine until it can be drained.

What is a urostomy?

A urostomy is a stoma that connects to the urinary tract and makes it possible for urine to drain out of the body when regular urination cannot occur. The stoma has no muscle, so it cannot control urine flow, causing a continuous flow. An external pouch collects urine flowing through the stoma. Ileal conduit and cutaneous ureterostomy are the two main types of urostomy.

Ileal Conduit

An ileal conduit uses a section of the bowel—usually the small intestine—surgically removed from the digestive tract and repositioned to serve as a passage, or conduit, for urine from the ureters to a stoma. One end of the conduit attaches to the ureters; the other end attaches to the stoma. The surgeon reconnects the bowel where the section was removed so that it functions normally. The urine flows through the newly formed ileal conduit and the stoma into an external pouch.

Cutaneous Ureterostomy

In cutaneous ureterostomy, the surgeon detaches one or both ureters and attaches them directly to a stoma. This type of urostomy is not as common as an ileal conduit because of a higher complication rate and the need for follow-up surgery. A surgeon performs cutaneous ureterostomy when the bowel cannot be used to create a stoma because of certain diseases and conditions or exposure to high doses of radiation.

What is continent urinary diversion?

Continent urinary diversion is an internal reservoir that a surgeon creates from a section of the bowel. Urine flows through the ureters into the reservoir and is drained by the patient. Continent urinary diversion does not require an external pouch. Continent urinary diversion consists of two main types, continent cutaneous reservoir and bladder substitute.

Continent Cutaneous Reservoir

A continent cutaneous reservoir connects to a stoma. A surgically created valve keeps urine from flowing out of the stoma. The patient inserts a catheter through the continent stoma to drain urine from the reservoir several times throughout the day. The stoma is very small—less than 1 inch wide—and sometimes can be hidden in the belly button.

Bladder Substitute

For a bladder substitute, also called a neobladder, a surgeon creates an internal reservoir that connects to the ureters at one end and to the urethra at the other. Since this type of reservoir connects to the urethra, urine empties from the reservoir in a more natural process, just as a person with a normal urinary tract would do when going to the bathroom with a natural bladder. However, the bladder substitute does not function as well as a natural bladder. In some cases, a catheter must be inserted through the urethra to completely empty the reservoir. A patient with this type of permanent diversion may have a higher chance of urinary incontinence—the accidental loss of urine. Only certain people qualify for this type of diversion, and surgeons carefully select eligible patients.

What special care is needed after urinary diversion surgery?

After urinary diversion surgery, a wound, ostomy, and continence (WOC) nurse or an enterostomal therapist helps patients learn how to take care of their permanent urinary diversions. WOC nurses and enterostomal therapists specialize in ostomy care and rehabilitation. Patients should ask how to care for their stomas and pouches.

Caring for a Continent Stoma

A continent stoma requires daily care.Care focuses on maintaining a clean and healthy stoma by

• wiping away extra mucus
• washing the stoma and surrounding skin with mild soap and water
• rinsing the stoma thoroughly
• drying the stoma completely

Caring for a Noncontinent Stoma

A noncontinent stoma also requires basic daily care. Care focuses on maintaining a suitable and healthy skin area for attachment of the pouch by

• wiping away extra mucus
• washing the stoma and surrounding skin with mild soap and water
• rinsing the stoma thoroughly
• drying the stoma completely

Patients should inspect their stoma and skin and notify their health care providers of any changes, specifically evidence of skin breakdown, typically in an area where urine leaks between the pouch and stoma.

Caring for a Pouch

A person with an ileal conduit or with cutaneous ureterostomy also works with WOC nurses or enterostomal therapists to learn how to care for an external pouch. The pouch system usually consists of two pieces—a barrier that sticks to the skin, known as a wafer, and a disposable plastic bag or pouch that attaches to the barrier. Sometimes the barrier and pouch are one unit. The barrier protects the skin from urine and is designed to be as gentle as possible on the skin. The length of time the barrier stays sealed to the skin depends on many things, such as whether the barrier fits properly, the condition of the skin around the stoma, the patient’s physical activity level, and the shape of the body around the stoma.

The pouch has a drain valve at the bottom so the patient can empty it into a toilet without removing the pouch from the stoma. During the day, most patients need to empty the pouch about as often as they used the bathroom before having urinary diversion surgery. Patients should empty the pouch when it is about one-third to one-half full. At night, patients can attach a piece of flexible tubing to the drain valve on the pouch to let urine flow into a bigger pouch during sleep.

Patients should rinse and clean the pouch daily and change it every 5 to 7 days. When changing a pouch, patients need to clean the skin around the stoma with a wet towelette or washcloth. The skin should be completely dry before applying a new pouch. If the constant flow of urine from the stoma irritates the skin, patients can use protective skin wipes or an ostomy powder designed to protect the skin around the stoma.

Wearing a urostomy pouch does not require special clothing. Modern pouches are designed to lie flat against the body so they aren’t noticeable under most clothing. A patient can tuck the pouch inside elastic undergarments or between undergarments and outer clothing. A simple pouch cover adds comfort by absorbing sweat and keeping the plastic pouch from resting against the skin. Cotton knit or stretch undergarments may give extra support and security. Some people with urostomies wear a belt that attaches to the pouch system and wraps around the waist. The belt supports the pouch system and, for some people, provides a sense of security.

Caring for a Continent Cutaneous Reservoir

For a continent cutaneous reservoir, patients learn how to insert a catheter through the stoma or urethra to drain the internal reservoir. Patients can drain the reservoir by inserting the catheter while standing in front of the toilet or sitting on the toilet. During the first few weeks after urinary diversion surgery, patients need to drain the internal reservoir every couple of hours. Over time, the reservoir capacity will increase and patients will be able to go 4 to 6 hours between reservoir drainings. Patients should wash their hands with soap and water each time they use a catheter. Before and after catheterization, patients should clean the stoma and skin around it with a wet towelette or washcloth and completely dry the stoma and skin.

The reservoir is made from part of the bowel, so it may produce mucus that normally lines the digestive tract. To clear this mucus, patients may need to irrigate, or flush out, the reservoir using a syringe with sterile water or normal saline. Patients should talk with a WOC nurse, an enterostomal therapist, or a urologist—a doctor who specializes in the urinary tract—about how often they should irrigate the reservoir.

Infection

Bacteria often enter urostomies and continent urinary diversions and begin growing in number. At times, bacterial overgrowth causes a symptomatic urinary tract infection. Symptoms of infection may include

• fever
• milky urine or urine containing extra mucus
• strong-smelling urine
• back pain
• poor appetite
• nausea
• vomiting

Patients with symptoms of infection should call their health care providers at once. Drinking eight full glasses of water every day can help prevent infection by flushing out bacteria and keeping bacterial counts low. Patients should talk with their health care providers about appropriate times to have their urine tested and when to have treatment with antibiotics. Urine testing and infection treatment play a critical role in successful long-term care with minimal complications.

Activities

To help the stoma heal, patients need to restrict their activities, including driving and heavy lifting, during the first 2 to 3 weeks after urinary diversion surgery. Once the stoma has healed, patients should be able to do most of the activities they enjoyed before urinary diversion surgery, even swimming and other water sports. The only exceptions may be contact sports such as football or karate. Patients whose jobs include strenuous physical activities should talk with their health care providers and employers about making adjustments to their job responsibilities.

Relationships

Patients may worry that people will have negative reactions to their urinary diversion. Most people will never know patients are wearing a pouch or have a continent urinary diversion. Friends and relatives are likely to be aware of the patient’s health problems. However, only a spouse, intimate partner, or primary caretaker needs to know the details of the urinary diversion. Patients can choose how much they share about their condition.

Urinary diversion surgery may reduce sexual function, especially when the bladder has been removed because of cancer. Patients who have good sexual function may resume sexual activities after urinary diversion surgery as soon as their health care providers say it is safe. Patients should talk with their health care providers about any concerns they have about maintaining a satisfying sexual relationship. Health care providers can give information about ways to protect the stoma during sexual activity. Patients may want to ask about specially designed apparel to enhance intimacy for people with urostomies. Communicating with a sexual partner is essential. Patients should share their concerns and wishes and listen carefully to their partner’s concerns.

Eating, Diet, and Nutrition

After urinary diversion surgery, patients will likely be able to resume their normal diet. Some foods, such as asparagus and seafood, may cause urine to have a stronger odor, which may be noticeable when emptying a pouch. If odor is a concern, patients should talk with their health care providers about changes in diet. Patients should also talk with their health care providers about their dietary needs. Some patients with continent urinary reservoirs have a chance of vitamin B deficiency and may require lifelong vitamin B injections. This requirement is only for a specific type of diversion and should be discussed with the health care provider in detail.

Points to Remember

• Urinary diversion is a surgical procedure that reroutes the normal flow of urine out of the body when urine flow is blocked.
• Urinary diversion can be temporary or permanent, depending on the reason for the procedure.
• Temporary urinary diversion reroutes the flow of urine for several days or weeks. This type of urinary diversion includes a nephrostomy and urinary catheterization.
• A nephrostomy involves a small tube inserted through the skin directly into a kidney.
• Urinary catheterization involves placing a thin, flexible tube––called a catheter––into the bladder to drain urine.
• Permanent urinary diversion requires surgery to reroute urine flow to an external pouch through an opening in the wall of the abdomen, called a stoma, or to a surgically created internal reservoir.
• Surgeons perform permanent urinary diversion when a patient has a damaged bladder or no longer has a bladder.
• The two permanent types of urinary diversion include urostomy and continent urinary diversion.
• A urostomy is a stoma that connects to the urinary tract and makes it possible for urine to drain out of the body when regular urination cannot occur.
• Continent urinary diversion is an internal reservoir that a surgeon creates from a section of the bowel.
• After urinary diversion surgery, a wound, ostomy, and continence (WOC) nurse or an enterostomal therapist helps patients learn how to take care of their permanent urinary diversions.

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.

What is the urinary tract?

The urinary tract is the body’s drainage system for removing wastes and extra water. The urinary tract includes two kidneys, two ureters, a bladder, and a urethra. The kidneys are a pair of bean-shaped organs, each about the size of a fist and located below the ribs, one on each side of the spine, toward the middle of the back. Every minute, a person’s kidneys filter about 3 ounces of blood, removing wastes and extra water. The wastes and extra water make up the 1 to 2 quarts of urine an adult produces each day. Children produce less urine each day; the amount produced depends on their age. The urine travels from the kidneys down two narrow tubes called the ureters. The urine is then stored in a balloonlike organ called the bladder. When the bladder empties, urine flows out of the body through a tube called the urethra at the bottom of the bladder.

What does “imaging” mean?

In medicine, “imaging” is the general term for any technique used to provide pictures of bones and organs inside the body. Imaging techniques include conventional radiology, or x-rays; ultrasound; magnetic resonance imaging (MRI); computerized tomography (CT) scans; and radionuclide scans. Imaging helps the health care provider see the causes of medical problems.

What problems could require imaging of the urinary tract?

Imaging can help the health care provider find the cause of

• urinary retention—the inability to empty the bladder completely
• urinary frequency—urination eight or more times a day
• urinary urgency—the inability to delay urination
• urinary incontinence—the accidental loss of urine
• blockage of urine
• abdominal mass—swelling in a specific part of the abdomen
• pain in the groin or lower back
• blood in the urine
• high blood pressure
• kidney failure

One symptom can have several possible causes. The health care provider can use imaging techniques to determine, for example, whether a urinary tract stone or an enlarged prostate is blocking urine flow. Imaging can help clarify kidney diseases, tumors, urinary tract infections (UTIs), urinary retention, small bladder capacity, and urinary reflux—the backward flow of urine.

What steps does the health care provider take before ordering imaging tests?

Before ordering imaging tests, the health care provider

• asks about specific urinary tract symptoms, when they began, and their frequency
• considers general medical history, including any major illnesses or surgeries
• may ask female patients whether pregnancy is suspected
• asks about medication use—both prescription and over the counter—the amount of fluid consumed each day, and the use of alcohol and caffeine
• performs a physical exam

These steps help the health care provider determine the possible causes of the urinary tract problems and what to look for in an imaging test.

What are the imaging techniques?

The health care provider can use several different imaging techniques depending on factors such as the person’s general medical history and urinary tract symptoms.

Conventional Radiology

X-ray machines have been used to diagnose diseases for about 100 years. X-rays of the urinary tract can help highlight a kidney stone or tumor that could be blocking the flow of urine and causing pain. For men, an x-ray also shows the size and shape of the prostate—a walnut-shaped gland that surrounds the urethra at the neck of the bladder and supplies fluid that goes into semen. Conventional x-rays do involve some exposure to ionizing radiation—radiation that is strong enough to damage some cells. Two common x-ray procedures include the injection of a special dye, called contrast medium, which shows the shape of the urinary tract.

Intravenous pyelogram (IVP). An IVP is an x-ray of the urinary tract. Contrast medium is injected into a vein in the person’s arm, travels through the body to the kidneys, and makes urine visible on the x-ray. The contrast medium also shows any blockage in the urinary tract. The procedure is performed in a health care provider’s office, outpatient center, or hospital by an x-ray technician, and the images are interpreted by a radiologist—a doctor who specializes in medical imaging; anesthesia is not needed. An IVP can help locate problems in the kidneys, ureters, or bladder that may be caused by urinary retention or reflux.

Voiding cystourethrogram (VCUG). A VCUG is an x-ray image of the bladder and urethra taken while the bladder is full and during urination, also called voiding. As the person lies on the x-ray table, a health care provider inserts the tip of a thin, flexible tube called a catheter through the urethra into the bladder. The bladder is filled with contrast medium to make it clearly visible on the x-ray images. The x-rays are taken from various angles while the bladder is full of contrast medium. The catheter is then removed and x-ray images are taken during urination. The procedure is performed in a health care provider’s office, outpatient center, or hospital by an x-ray technician. The technician is supervised by a radiologist while the images are taken. The radiologist then interprets the images. Anesthesia is not needed, but sedation may be used for some people. A VCUG can reveal abnormalities of the inside of the urethra and bladder and is usually used for children to detect vesicoureteral reflux—the abnormal flow of urine from the bladder back into the upper urinary tract. A VCUG can also show whether the flow of urine is normal when the bladder empties, blockages from an enlarged prostate in men, and an abnormal bladder position in women.

Ultrasound

Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. The transducer can be moved to different angles to make it possible to examine different organs. The procedure is performed in a health care provider’s office, outpatient center, or hospital by a specially trained technician, and the images are interpreted by a radiologist; anesthesia is not needed. The images can be used to provide information that is valuable in diagnosing and treating a variety of diseases and conditions.

Abdominal ultrasound. In abdominal ultrasound, the health care provider applies a gel to the person’s abdomen and moves a hand-held transducer over the skin. The gel allows the transducer to glide easily, and it improves the transmission of the signals.

The procedure is performed in a health care provider’s office, outpatient center, or hospital by a specially trained technician, and the images are interpreted by a radiologist; anesthesia is not needed. An abdominal ultrasound can create images of the entire urinary tract. The images can show damage or abnormalities in the urinary tract. Abdominal ultrasounds are also commonly used to take pictures of fetuses in the womb and of a woman’s ovaries and uterus.

Transrectal ultrasound with prostate biopsy. Transrectal ultrasound is most often used to examine the prostate. In a transrectal ultrasound, the health care provider inserts a transducer slightly larger than a pen into the man’s rectum next to the prostate. The ultrasound image shows the size of the prostate and any abnormal-looking areas, such as tumors. Transrectal ultrasound cannot be used to definitively diagnose prostate cancer.

To determine whether a tumor is cancerous, the health care provider performs a biopsy. For the biopsy, the health care provider uses the transducer and ultrasound images to guide a needle to the prostate. The needle is then used to remove a few pieces of prostate tissue for examination with a microscope. A transrectal ultrasound with prostate biopsy is usually performed in a health care provider’s office, outpatient facility, or hospital by a doctor; light sedation and local anesthesia are used. The biopsied prostate tissue is examined in a laboratory by a pathologist—a doctor who specializes in diagnosing diseases. The biopsy can reveal whether prostate cancer is present.

MRI

Magnetic resonance imaging is a test that takes pictures of the body’s internal organs and soft tissues without using x-rays. MRI machines use radio waves and magnets to produce detailed pictures of the body’s internal organs and soft tissues. 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 where the images are taken. The device 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. During an MRI, the person is usually awake but must remain perfectly still while the images are being taken. A sequence of images taken from different angles may be needed to create a detailed picture of the urinary tract. During the sequencing, the person will hear loud, mechanical knocking and humming noises. The procedure is performed in an outpatient center or hospital by a specially trained technician, and the images are interpreted by a radiologist; anesthesia is not needed, though light sedation may be used for people with a fear of confined spaces.

Magnetic resonance angiogram (MRA). An MRA is a type of MRI that provides the most detailed view of kidney arteries—the blood vessels that supply blood to the kidneys. An MRA can show kidney artery stenosis, which is the narrowing of a kidney artery that restricts blood flow to the kidney. Kidney artery stenosis can cause high blood pressure and lead to reduced kidney function and eventually kidney failure.

CT Scans

Computerized tomography 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 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. The procedure is performed in an outpatient center or hospital by a specially trained technician, and the images are interpreted by a radiologist; anesthesia is not needed. CT scans can show stones in the urinary tract, obstructions, infections, cysts, tumors, and traumatic injuries.

Radionuclide Scans

A radionuclide scan is an imaging technique that relies on the detection of small amounts of radiation after injection of radioactive chemicals. Because the dose of the radioactive chemicals is small, the risk of causing damage to cells is low. Special cameras and computers are used to create images of the radioactive chemicals as they pass through the urinary tract. Radionuclide scans are performed at a health care provider’s office, outpatient center, or hospital by a specially trained technician, and the images are interpreted by a radiologist; anesthesia is not needed. Radioactive chemicals injected into the blood can provide information about kidney function. Radioactive chemicals can also be put into the fluids used to fill the bladder and urethra for x-ray, MRI, and CT imaging.

What preparations are needed for an imaging test?

Preparations for an imaging test mostly depend on the purpose and type of test. In general, the health care provider will want to know whether the person is allergic to any foods or medications, is pregnant, or has had any recent illnesses or medical conditions. Specific preparations could include any of the following:

• fasting for 12 hours before the test
• drinking several glasses of water 2 hours before the test so the bladder is full—for some ultrasound tests
• taking a laxative, which is a medication that loosens stool and increases bowel movements, to clear the colon—for a transrectal ultrasound
• taking an enema, which involves flushing water, laxative, or sometimes a mild soap solution into the anus using a special squirt bottle, about 4 hours before the test—for a transrectal ultrasound
• talking with the technical staff about any implanted devices that may have metal parts that will affect MRI or MRA images, such as heart pacemakers, intrauterine devices (IUDs), hip replacements, and implanted ports for catheterization; metal plates, pins, screws, and surgical staples, as well as any bullets or shrapnel in the body, may also cause a problem if they have been in place fewer than 4 to 6 weeks
• taking a sedative before an MRI or CT scan if the person feels anxious or has difficulty holding still in enclosed spaces

People undergoing an imaging test should listen to the health care provider’s instructions carefully and ask questions if something is not understood.

What happens after imaging tests?

After most imaging tests, the person can immediately resume normal activity. Tests that involved placing a catheter in the urethra may produce some mild discomfort for a few hours after the procedure. Drinking an 8-ounce glass of water every half-hour for 2 hours may help reduce the discomfort. The health care provider may recommend taking a warm bath or holding a warm, damp washcloth over the urethral opening to relieve the discomfort. A transrectal ultrasound may produce some discomfort. A prostate biopsy may produce pain in the area of the rectum and the perineum, which is between the rectum and the scrotum. A prostate biopsy may also produce blood in the urine and semen.

For catheterization or biopsy, the health care provider may prescribe an antibiotic for 1 or 2 days to prevent an infection. People with signs of infection—including pain, chills, or fever—should call a health care provider immediately.

Some people have reactions to the contrast medium or the sedatives, though the risks are generally low. Signs of contrast medium reactions include hives, itching, nausea, vomiting, headache, and dizziness. Contrast medium can cause kidney damage in people with certain conditions, such as impaired kidney function and diabetes. In most people, the kidney damage has no symptoms and goes away within a week or so. In rare cases, contrast medium causes lasting kidney damage. Signs of kidney damage include

• high blood pressure
• little or no urination
• edema—swelling, usually in the hands, face, feet, or ankles
• tiredness
• generalized itching or numbness
• headaches
• weight loss
• appetite loss
• sleep problems

Reactions to sedatives are rare but possible. Signs of sedative reactions include changes in breathing and heart rate. People with signs of reactions to the contrast medium or the sedatives should call a health care provider immediately.

How soon will test results be available?

The results of simple tests such as x-rays and abdominal ultrasound can be discussed with the health care provider soon after the test. Results of other tests such as a prostate tissue biopsy, MRI, and CT scans may take several days to come back. The health care provider will talk with the patient about these results.

Points to Remember

• The urinary tract is the body’s drainage system for removing wastes and extra water.
• “Imaging” is the general term for any technique used to provide pictures of bones and organs inside the body.
• Imaging helps the health care provider find the causes of urinary tract problems.
• The health care provider will consider a person’s general medical history and urinary tract symptoms to decide what imaging technique to use.
• Urinary tract imaging techniques include conventional radiology, or x-rays; ultrasound; magnetic resonance imaging (MRI); computerized tomography (CT) scans; and radionuclide scans.
• Preparations for an imaging test mostly depend on the purpose and type of test.
• After most imaging tests, the person can immediately resume normal activity.
• Results for simple tests are available soon after the test, while other test results may take several days to come back.

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.

What is the urinary tract?

The urinary tract is the body’s drainage system for removing wastes and extra fluid. The urinary tract includes two kidneys, two ureters, a bladder, and a urethra. The kidneys are two bean-shaped organs, each about the size of a fist. They are located just below the rib cage, one on each side of the spine. Every day, the kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2 quarts of u?rine, composed of wastes and extra fluid. Children produce less urine than adults. The amount produced depends on their age. The urine flows from the kidneys to the bladder through tubes called ureters. The bladder stores urine until releasing it through urination. When the bladder empties, urine flows out of the body through a tube called the urethra at the bottom of the bladder.

The kidneys and urinary system keep fluids and natural chemicals in the body balanced. While a baby is developing in the mother’s womb, called prenatal development, the placenta—a temporary organ joining mother and baby—controls much of that balance. The baby’s kidneys begin to produce urine at about 10 to 12 weeks after conception. However, the mother’s placenta continues to do most of the work until the last few weeks of the pregnancy. Wastes and extra water are removed from the baby’s body through the umbilical cord. The baby’s urine is released into the amniotic sac and becomes part of the amniotic fluid. This fluid plays a role in the baby’s lung development.

What causes urine blockage in newborns?

Many types of defects in the urinary tract can cause urine blockage:

• Vesicoureteral reflux (VUR). Most children with VUR are born with a ureter that did not grow long enough during development in the womb. The valve formed by the ureter pressing against the bladder wall does not close properly, so urine backs up—refluxes—from the bladder to the ureter and eventually to the kidney. Severe reflux may prevent a kidney from developing normally and may increase the risk for damage from infections after birth. VUR usually affects only one ureter and kidney, though it can affect both ureters and kidneys.
• Ureteropelvic junction (UPJ) obstruction. If urine is blocked where the ureter joins the kidney, only the kidney swells. The ureter remains a normal size. UPJ obstruction usually occurs in only one kidney.

• Bladder outlet obstruction (BOO). BOO describes any blockage in the urethra or at the opening of the bladder. Posterior urethral valves (PUV), the most common form of BOO seen in newborns and during prenatal ultrasound exams, is a birth defect in boys in which an abnormal fold of tissue in the urethra keeps urine from flowing freely out of the bladder. This defect may cause swelling in the entire urinary tract, including the urethra, bladder, ureters, and kidneys.
• Ureterocele. If the end of the ureter does not develop normally, it can bulge, creating a ureterocele. The ureterocele may obstruct part of the ureter or the bladder.

Some babies are born with genetic conditions that affect several different systems in the body, including the urinary tract:

• Prune belly syndrome (PBS). PBS is a group of birth defects involving poor development of the abdominal muscles, enlargement of the ureters and bladder, and both testicles remaining inside the body instead of descending into the scrotum. The skin over the abdomen is wrinkled, giving the appearance of a prune. PBS usually occurs in boys, and most children with PBS have hydronephrosis—swelling in the kidney—and VUR.
• Esophageal atresia (EA). EA is a birth defect in which the esophagus—the muscular tube that carries food and liquids from the mouth to the stomach—lacks the opening for food to pass into the stomach. Babies born with EA may also have problems with their spinal columns, digestive systems, hearts, and urinary tracts.
• Congenital heart defects. Heart defects range from mild to life threatening. Children born with heart defects also have a higher rate of problems in the urinary tract than children in the general population, suggesting that some types of heart and urinary defects may have a common genetic cause.

Urine blockage can also be caused by spina bifida and other birth defects that affect the spinal cord. These defects may interrupt nerve signals between the bladder, spinal cord, and brain, which are needed for urination, and lead to urinary retention—the inability to empty the bladder completely—in newborns. Urine that remains in the bladder can reflux into the ureters and kidneys, causing swelling.

What are the symptoms of urine blockage in newborns?

Before leaving the hospital, a baby with urine blockage may urinate only small amounts or may not urinate at all. As part of the routine newborn exam, the health care provider may feel an enlarged kidney or find a closed urethra, which may indicate urine blockage. Sometimes urine blockage is not apparent until a child develops symptoms of a urinary tract infection (UTI), including

• fever
• irritability
• not eating
• nausea
• diarrhea
• vomiting
• cloudy, dark, bloody, or foul-smelling urine
• urinating often

If these symptoms persist, the child should see a health care provider. A child 2 months of age or younger with a fever should see a health care provider immediately. The health care provider will ask for a urine sample to test for bacteria.

What are the complications of urine blockage before and after birth?

When a defect in the urinary tract blocks the flow of urine, the urine backs up and causes the ureters to swell, called hydroureter, and hydronephrosis.

Hydronephrosis is the most common problem found during prenatal ultrasound of a baby in the womb. The swelling may be easy to see or barely detectable. The results of hydronephrosis may be mild or severe, yet the long-term outcome for the child’s health cannot always be predicted by the severity of swelling. Urine blockage may damage the developing kidneys and reduce their ability to filter. In the most severe cases of urine blockage, where little or no urine leaves the baby’s bladder, the amount of amniotic fluid is reduced to the point that the baby’s lung development is threatened.

After birth, urine blockage may raise a child’s risk of developing a UTI. Recurring UTIs can lead to more permanent kidney damage.

How is urine blockage in newborns diagnosed?

Defects of the urinary tract may be diagnosed before or after the baby is born.

Diagnosis before Birth

Tests during pregnancy can help determine if the baby is developing normally in the womb.

• Ultrasound. Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. A prenatal ultrasound can show internal organs within the baby. The procedure is performed in a health care provider’s office, outpatient center, or hospital by a specially trained technician, and the images are interpreted by
  • a radiologist—a doctor who specializes in medical imaging, or
  • an obstetrician—a doctor who delivers babies

The images can show enlarged kidneys, ureters, or bladders in babies.

• Amniocentesis. Amniocentesis is a procedure in which amniotic fluid is removed from the mother’s womb for testing. The procedure can be performed in the health care provider’s office, and local anesthetic may be used. The health care provider inserts a thin needle through the abdomen into the uterus to obtain a small amount of amniotic fluid. Cells from the fluid are grown in a lab and then analyzed. The health care provider usually uses ultrasound to find the exact location of the baby. The test can show whether the baby has certain birth defects and how well the baby’s lungs are developing.
• Chorionic villus sampling (CVS). CVS is the removal of a small piece of tissue from the placenta for testing. The procedure can be performed in the health care provider’s office; anesthesia is not needed. The health care provider uses ultrasound to guide a thin tube or needle through the vagina or abdomen into the placenta. Cells are removed from the placenta and then analyzed. The test can show whether the baby has certain genetic defects.

Most healthy women do not need all of these tests. Ultrasound exams during pregnancy are routine. Amniocentesis and CVS are recommended only when a risk of genetic problems exists because of family history or a problem is detected during an ultrasound. Amniocentesis and CVS carry a slight risk of harming the baby and mother or ending the pregnancy in miscarriage, so the risks should be carefully considered.

Diagnosis after Birth

Different imaging techniques can be used in infants and children to determine the cause of urine blockage.

• Ultrasound. Ultrasound can be used to view the child’s urinary tract. For infants, the image is clearer than could be achieved while the baby was in the womb.
• Voiding cystourethrogram (VCUG). VCUG is an x-ray image of the bladder and urethra taken while the bladder is full and during urination, also called voiding. The procedure is performed in an outpatient center or hospital by an x-ray technician supervised by a radiologist, who then interprets the images. While anesthesia is not needed, sedation may be used for some children. The bladder and urethra are filled with a special dye, called contrast medium, to make the structures clearly visible on the x-ray images. The x-ray machine captures images of the contrast medium while the bladder is full and when the child urinates. The test can show reflux or blockage of the bladder due to an obstruction, such as PUV.
• Radionuclide scan. A radionuclide scan is an imaging technique that detects small amounts of radiation after a person is injected with radioactive chemicals. The dose of the radioactive chemicals is small; therefore, the risk of causing damage to cells is low. Radionuclide scans are performed in an outpatient center or hospital by a specially trained technician, and the images are interpreted by a radiologist. Anesthesia is not needed. Special cameras and computers are used to create images of the radioactive chemicals as they pass through the kidneys. Radioactive chemicals injected into the blood can provide information about kidney function.

How is urine blockage in newborns treated?

Treatment for urine blockage depends on the cause and severity of the blockage. Hydronephrosis discovered before the baby is born rarely requires immediate action, especially if it is only on one side. The condition often goes away without any treatment before or after birth. The health care provider should keep track of the condition with frequent ultrasounds.

Surgery

If the urine blockage threatens the life of the unborn baby, a fetal surgeon may recommend surgery to insert a shunt or correct the problem causing the blockage. A shunt is a small tube that can be inserted into the baby’s bladder to release urine into the amniotic sac. The procedure is similar to amniocentesis, in that a needle is inserted through the mother’s abdomen. Ultrasound guides placement of the shunt, which is attached to the end of the needle. Alternatively, an endoscope—a small, flexible tube with a light—can be used to place a shunt or to repair the problem causing the blockage. Fetal surgery carries many risks, so it is performed only in special circumstances, such as when the amniotic fluid is absent and the baby’s lungs are not developing or when the kidneys are severely damaged.

If the urinary defect does not correct itself after the child is born, and the child continues to have urine blockage, surgery may be needed to remove the obstruction and restore urine flow. The decision to operate depends on the degree of blockage. After surgery, a small tube, called a stent, may be placed in the ureter or urethra to keep it open temporarily while healing occurs.

Antibiotics

Antibiotics are bacteria-fighting medications. A child with possible urine blockage or VUR may be given antibiotics to prevent UTIs from developing until the urinary defect corrects itself or is corrected with surgery.

Intermittent Catheterization

Intermittent catheterization may be used for a child with urinary retention due to a nerve disease. The parent or guardian, and later the child, is taught to drain the bladder by inserting a thin tube, called a catheter, through the urethra to the bladder. Emptying the bladder in this way helps to decrease kidney damage, urine leakage, and UTIs.

Eating, Diet, and Nutrition

Researchers have not found that a mother’s eating, diet, and nutrition play a role in causing or preventing urine blockage in newborns.

Points to Remember

• Many types of defects in the urinary tract can cause urine blockage:
  • vesicoureteral reflux (VUR)
  • ureteropelvic junction (UPJ) obstruction
  • bladder outlet obstruction (BOO), such as posterior urethral valves (PUV)
  • ureterocele
• Some babies are born with genetic conditions that affect several different systems in the body, including the urinary tract:
  • prune belly syndrome (PBS)
  • esophageal atresia (EA)
  • congenital heart defects
• Urine blockage can also be caused by spina bifida and other birth defects that affect the spinal cord.
• Before leaving the hospital, a baby with urine blockage may urinate only small amounts or may not urinate at all. As part of the routine newborn exam, the health care provider may feel an enlarged kidney or find a closed urethra, which may indicate urine blockage. Sometimes urine blockage is not apparent until a child develops symptoms of a urinary tract infection (UTI).
• When a defect in the urinary tract blocks the flow of urine, the urine backs up and causes the ureters to swell, called hydroureter, and hydronephrosis.
• Defects of the urinary tract may be discovered before or after the baby is born.
• Prenatal tests include ultrasound, amniocentesis, and chorionic villus sampling (CVS).
• Different imaging techniques, including ultrasound, voiding cystourethrogram (VCUG), and radionuclide scan, can be used in infants and children to determine the cause of urine blockage.
• Treatment for urine blockage depends on the cause and severity of the blockage. Hydronephrosis discovered before the baby is born rarely requires immediate action, especially if it is only on one side. Treatments for more serious conditions include
  • surgery
  • antibiotics
  • intermittent catheterization

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.

What is the urinary tract?

The urinary tract is the body’s drainage system for removing wastes and extra water. The urinary tract includes two kidneys, two ureters, a bladder, and a urethra. Blood flows through the kidneys, and the kidneys filter out wastes and extra water, making urine. The urine travels down two narrow tubes called the ureters. The urine is then stored in a muscular, balloonlike organ called the bladder. The bladder swells into a round shape when it is full and gets smaller as it empties. When the bladder empties, urine flows out of the body through the urethra.

What is the lower urinary tract and how does it work?

The lower urinary tract includes the bladder and urethra. The bladder sits in the pelvis and is attached to other organs, muscles, and the pelvic bones, which hold it in place. The urethra is a tube at the bottom of the bladder that carries urine from the bladder to the outside of the body.

The lower urinary tract works by coordinating the muscles of the bladder wall with the sphincters, which are circular muscles that surround the area of the bladder that opens into the urethra. The muscles of the bladder wall relax as the bladder fills with urine. If the urinary tract is healthy, the bladder can hold up to 2 cups, or 16 ounces, of urine comfortably for 2 to 5 hours. The sphincters close tightly like rubber bands around the bladder to help keep urine from leaking. As the bladder fills, the need to urinate becomes stronger and stronger, until the bladder reaches its limit. Urination is the process of emptying the bladder. To urinate, the brain signals the bladder muscles to tighten, squeezing urine out of the bladder. At the same time, the brain signals the sphincters to relax. As the sphincters relax, urine exits the bladder through the urethra. When all the signals occur in the correct order, normal urination occurs.

More information about the urinary tract and urinary tract problems is provided in the NIDDK health topic, The Urinary Tract and How It Works.

What is urodynamic testing?

Urodynamic testing is any procedure that looks at how well the bladder, sphincters, and urethra are storing and releasing urine. Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely. Urodynamic tests can also show whether the bladder is having involuntary contractions that cause urine leakage. A health care provider may recommend urodynamic tests if symptoms suggest problems with the lower urinary tract. Lower urinary tract symptoms (LUTS) include

• urine leakage
• frequent urination
• painful urination
• sudden, strong urges to urinate
• problems starting a urine stream
• problems emptying the bladder completely
• recurrent urinary tract infections

Urodynamic tests range from simple observation to precise measurements using sophisticated instruments. For simple observation, a health care provider may record the length of time it takes a person to produce a urinary stream, note the volume of urine produced, and record the ability or inability to stop the urine flow in midstream. For precise measurements, imaging equipment takes pictures of the bladder filling and emptying, pressure monitors record the pressures inside the bladder, and sensors record muscle and nerve activity. The health care provider will decide the type of urodynamic test based on the person’s health information, physical exam, and LUTS. The urodynamic test results help diagnose the cause and nature of a lower urinary tract problem.

Most urodynamic tests do not involve special preparations, though some tests may require a person to make a change in fluid intake or to stop taking certain medications. Depending on the test, a person may be instructed to arrive for testing with a full bladder.

What are the urodynamic tests?

Urodynamic tests include

• uroflowmetry
• postvoid residual measurement
• cystometric test
• leak point pressure measurement
• pressure flow study
• electromyography
• video urodynamic tests

Uroflowmetry

Uroflowmetry is the measurement of urine speed and volume. Special equipment automatically measures the amount of urine and the flow rate—how fast the urine comes out. Uroflowmetry equipment includes a device for catching and measuring urine and a computer to record the data. During a uroflowmetry test, the person urinates privately into a special toilet or funnel that has a container for collecting the urine and a scale. The equipment creates a graph that shows changes in flow rate from second to second so the health care provider can see when the flow rate is the highest and how many seconds it takes to get there. 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. Uroflowmetry measurements are performed in a health care provider’s office; no anesthesia is needed.

Postvoid Residual Measurement

This urodynamic test measures the amount of urine left in the bladder after urination. The remaining urine is called the postvoid residual. Postvoid residual can be measured with ultrasound equipment that uses harmless sound waves to create a picture of the bladder. Bladder ultrasounds are performed in a health care provider’s office, radiology center, or hospital by a specially trained technician and interpreted by a doctor, usually a radiologist. Anesthesia is not needed. Postvoid residual can also be measured using a catheter—a thin flexible tube. A health care provider inserts the catheter through the urethra up into the bladder to remove and measure the amount of remaining urine. A postvoid residual of 100 milliliters or more is a sign that the bladder is not emptying completely. Catheter measurements are performed in a health care provider’s office, clinic, or hospital with local anesthesia.

Cystometric Test

A cystometric test measures how much urine the bladder can hold, how much pressure builds up inside the bladder as it stores urine, and how full it is when the urge to urinate begins. A catheter is used to empty the bladder completely. Then a special, smaller catheter is placed in the bladder. This catheter has a pressure-measuring device called a manometer. Another catheter may be placed in the rectum to record pressure there.

Once the bladder is emptied completely, the bladder is filled slowly with warm water. During this time, the person is asked to describe how the bladder feels and indicate when the need to urinate arises. When the urge to urinate occurs, the volume of water and the bladder pressure are recorded. The person may be asked to cough or strain during this procedure to see if the bladder pressure changes. A cystometric test can also identify involuntary bladder contractions. Cystometric tests are performed in a health care provider’s office, clinic, or hospital with local anesthesia.

Leak Point Pressure Measurement

This urodynamic test measures pressure at the point of leakage during a cystometric test. While the bladder is being filled for the cystometric test, it may suddenly contract and squeeze some water out without warning. The manometer measures the pressure inside the bladder when this leakage occurs. This reading may provide information about the kind of bladder problem that exists. The person may be asked to apply abdominal pressure to the bladder by coughing, shifting position, or trying to exhale while holding the nose and mouth. These actions help the health care provider evaluate the sphincters.

Pressure Flow Study

A pressure flow study measures the bladder pressure required to urinate and the flow rate a given pressure generates. After the cystometric test, the person empties the bladder, during which time a manometer is used to measure bladder pressure and flow rate. This pressure flow study helps identify bladder outlet blockage that men may experience with prostate enlargement. Bladder outlet blockage is less common in women but can occur with a cystocele or, rarely, after a surgical procedure for urinary incontinence. Pressure flow studies are performed in a health care provider’s office, clinic, or hospital with local anesthesia.

Electromyography

Electromyography uses special sensors to measure the electrical activity of the muscles and nerves in and around the bladder and the sphincters. If the health care provider thinks the urinary problem is related to nerve or muscle damage, the person may be given an electromyography. The sensors are placed on the skin near the urethra and rectum or on a urethral or rectal catheter. Muscle and nerve activity is recorded on a machine. The patterns of the nerve impulses show whether the messages sent to the bladder and sphincters are coordinated correctly. Electromyography is performed by a specially trained technician in a health care provider’s office, outpatient clinic, or hospital. Anesthesia is not needed if sensors are placed on the skin. Local anesthesia is needed if sensors are placed on a urethral or rectal catheter.

Video Urodynamic Tests

Video urodynamic tests take pictures and videos of the bladder during filling and emptying. The imaging equipment may use x-rays or ultrasound. If x-ray equipment is used, the bladder will be filled with a special fluid, called contrast medium, that shows up on x-rays. X-rays are performed by an x-ray technician in a health care provider’s office, outpatient facility, or hospital; anesthesia is not needed. If ultrasound equipment is used, the bladder is filled with warm water and harmless sound waves are used to create a picture of the bladder. The pictures and videos show the size and shape of the bladder and help the health care provider understand the problem. Bladder ultrasounds are performed in a health care provider’s office, radiology center, or hospital by a specially trained technician and interpreted by a doctor, usually a radiologist. Although anesthesia is not needed for the ultrasound, local anesthesia is needed to insert the catheter to fill the bladder.

What happens after urodynamic tests?

After having urodynamic tests, a person may feel mild discomfort for a few hours when urinating. Drinking an 8-ounce glass of water every half-hour for 2 hours may help to reduce the discomfort. The health care provider may recommend taking a warm bath or holding a warm, damp washcloth over the urethral opening to relieve the discomfort.

An antibiotic may be prescribed for 1 or 2 days to prevent infection, but not always. People with signs of infection—including pain, chills, or fever—should call their health care provider immediately.

How soon will test results be available?

Results for simple tests such as cystometry and uroflowmetry are often available immediately after the test. Results of other tests such as electromyography and video urodynamic tests may take a few days to come back. A health care provider will talk with the patient about the results and possible treatments.

Points to Remember

• The urinary tract is the body’s drainage system for removing wastes and extra water.
• The lower urinary tract includes the bladder and urethra.
• Urodynamic testing is any procedure that looks at how well the bladder, sphincters, and urethra are storing and releasing urine.
• Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely.
• Urodynamic tests include uroflowmetry, postvoid residual measurement, cystometric test, leak point pressure measurement, pressure flow study, electromyography, and video urodynamic tests.
• Most urodynamic tests do not involve special preparations. Depending on the test, a person may be instructed to arrive for testing with a full bladder.
• After having urodynamic tests, a person may feel mild discomfort for a few hours when urinating.
• Results for simple tests are often available immediately after the test, while other test results may take a few days to come back.

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.

What is vesicoureteral reflux (VUR)?

Vesicoureteral reflux is the abnormal flow of urine from the bladder to the upper urinary tract. The urinary tract is the body’s drainage system for removing wastes and extra water. The urinary tract includes two kidneys, two ureters, a bladder, and a urethra. Blood flows through the kidneys, and the kidneys filter out wastes and extra water, making urine. The urine travels down two narrow tubes called the ureters. The urine is then stored in a balloonlike organ called the bladder. When the bladder empties, urine flows out of the body through a tube called the urethra at the bottom of the bladder.

In VUR, urine may flow back—reflux—into one or both ureters and, in some cases, to one or both kidneys. VUR that affects only one ureter and kidney is called unilateral reflux, and VUR that affects both ureters and kidneys is called bilateral reflux.

Who gets VUR?

Vesicoureteral reflux is more common in infants and young children, but older children and even adults can be affected. About 10 percent of children have VUR.¹ Studies estimate that VUR occurs in about 32 percent of siblings of an affected child. This rate may be as low as 7 percent in older siblings and as high as 100 percent in identical twins. These findings indicate that VUR is an inherited condition.²

What are the types of VUR?

The two types of VUR are primary and secondary. Most cases of VUR are primary and typically affect only one ureter and kidney. With primary VUR, a child is born with a ureter that did not grow long enough during the child’s development in the womb. The valve formed by the ureter pressing against the bladder wall does not close properly, so urine refluxes from the bladder to the ureter and eventually to the kidney. This type of VUR can get better or disappear as a child gets older. As a child grows, the ureter gets longer and function of the valve improves.

Secondary VUR occurs when a blockage in the urinary tract causes an increase in pressure and pushes urine back up into the ureters. Children with secondary VUR often have bilateral reflux. VUR caused by a physical defect typically results from an abnormal fold of tissue in the urethra that keeps urine from flowing freely out of the bladder.

VUR is usually classified as grade I through V, with grade I being the least severe and grade V being the most severe.

What are the symptoms of VUR?

In many cases, a child with VUR has no symptoms. When symptoms are present, the most common is a urinary tract infection (UTI). VUR can lead to infection because urine that remains in the child’s urinary tract provides a place for bacteria to grow. Studies estimate that 30 percent of children and up to 70 percent of infants with a UTI have VUR.²

What are the complications of VUR?

When a child with VUR gets a UTI, bacteria can move into the kidney and lead to scarring. Scarring of the kidney can be associated with high blood pressure and kidney failure. However, most children with VUR who get a UTI recover without long-term complications.

How is VUR diagnosed?

The most common tests used to diagnose VUR include

• Voiding cystourethrogram (VCUG). VCUG is an x-ray image of the bladder and urethra taken during urination, also called voiding. The bladder and urethra are filled with a special dye, called contrast medium, to make the urethra clearly visible. The x-ray machine captures a video of the contrast medium when the child urinates. The procedure is performed in a health care provider’s office, outpatient center, or hospital by an x-ray technician supervised by a radiologist—a doctor who specializes in medical imaging—who then interprets the images. Anesthesia is not needed, but sedation may be used for some children. This test can show abnormalities of the inside of the urethra and bladder.
• Radionuclide cystogram (RNC). RNC is a type of nuclear scan that involves placing radioactive material into the bladder. A scanner then detects the radioactive material as the child urinates or after the bladder is empty. The procedure is performed in a health care provider’s office, outpatient center, or hospital by a specially trained technician, and the images are interpreted by a radiologist. Anesthesia is not needed, but sedation may be used for some children. RNC is more sensitive than VCUG but does not provide as much detail of the bladder anatomy.
• Abdominal 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, including the kidneys and bladder. The procedure is performed in a health care provider’s office, outpatient center, or hospital by a specially trained technician, and the images are interpreted by a radiologist; anesthesia is not needed. Ultrasound may be used before VCUG or RNC if the child’s family or health care provider wants to avoid exposure to x-ray radiation or radioactive material.

Testing is usually done on

• infants diagnosed during pregnancy with urine blockage affecting the kidneys
• children younger than 5 years of age with a UTI
• children with a UTI and fever, called febrile UTI, regardless of age
• males with a UTI who are not sexually active, regardless of age or fever
• children with a family history of VUR, including an affected sibling

More information about urine blockage in infants is provided in the NIDDK health topic, Urine Blockage in Newborns.

VUR is an unlikely cause of UTI in some children, so these tests are not done until other causes of UTI are ruled out for

• children 5 years of age and older with a UTI
• children with a UTI but no fever
• sexually active males with a UTI

What other tests do children with VUR need?

Following diagnosis, children with VUR should have a general medical evaluation that includes blood pressure measurement, as high blood pressure is an indicator of kidney damage. If both kidneys are affected, a child’s blood should be tested for creatinine—a waste product of normal muscle breakdown. Healthy kidneys remove creatinine from the blood; when the kidneys are damaged, creatinine builds up in the blood. The urine may be tested for the presence of protein and bacteria. Protein in the urine is another indication of damaged kidneys.

Children with VUR should also be assessed for bladder/bowel dysfunction (BBD). BBD symptoms include

• having to urinate often or suddenly
• long periods of time between bathroom visits
• daytime wetting
• pain in the penis or perineum—the area between the anus and genitals
• posturing to prevent wetting
• constipation—a condition in which a child has fewer than two bowel movements in a week; the bowel movements may be painful
• fecal incontinence—inability to hold stool in the colon and rectum, which are parts of the large intestine

Children who have VUR along with any BBD symptoms are at greater risk of kidney damage due to infection.

How is primary VUR treated?

The standard treatment for primary VUR has included prompt treatment of UTIs and long-term use of antibiotics to prevent UTIs, also called antimicrobial prophylaxis, until VUR goes away on its own. Antibiotics are bacteria-fighting medications. Surgery has also been used in certain cases.

Several studies have raised questions about long-term use of antibiotics for prevention of UTIs. The studies found little or no effect on prevention of kidney damage. Long-term use may also make the child resistant to the antibiotic, meaning the medication does not work as well, and the child may be sicker longer and may need to take medications that are even stronger.

Current recommendations from the American Urological Association include the following:

• children younger than 1 year of age—continuous antibiotics should be used if a child has a history of febrile UTI or VUR grade III through V that was identified through screening
• children older than 1 year of age with BBD—continuous antibiotics should be used while BBD is being treated
• children older than 1 year of age without BBD—continuous antibiotics can be used at the discretion of the health care provider but is not automatically recommended; however, UTIs should be promptly treated

Surgery has traditionally been considered for a child with kidney infection, fever, and severe reflux that has not improved within a year. However, some health care providers recommend surgery when a scan of the kidneys shows evidence of inflammation. Several surgical approaches can be used to alter the ureter and prevent urine from refluxing.

Deflux, a gellike liquid containing complex sugars, is an alternative to surgery for treatment of VUR. A small amount of Deflux is injected into the bladder wall near the opening of the ureter. This injection creates a bulge in the tissue that makes it harder for urine to flow back up the ureter. The health care provider uses a special tube to see inside the bladder during the procedure. Deflux injection is an outpatient procedure done under general anesthesia, so the child can go home the same day.

How is secondary VUR treated?

Secondary VUR is treated by removing the blockage causing the reflux. Treatment may involve

• surgery
• antibiotics
• intermittent catheterization—draining the bladder by inserting a thin tube, called a catheter, through the urethra to the bladder

Eating, Diet, and Nutrition

Eating, diet, and nutrition have not been shown to play a role in causing or preventing VUR.

Points to Remember

• Vesicoureteral reflux (VUR) is the abnormal flow of urine from the bladder to the upper urinary tract.
• VUR is more common in infants and young children, but older children and even adults can be affected. About 10 percent of children have VUR.
• In many cases, a child with VUR has no symptoms. When symptoms are present, the most common is a urinary tract infection (UTI).
• When a child with VUR gets a UTI, bacteria can move into the kidney and lead to scarring. Scarring of the kidney can be associated with high blood pressure and kidney failure.
• Voiding cystourethrogram (VCUG), radionuclide cystogram (RNC), and abdominal ultrasound are used to diagnose VUR.
• Children with VUR should also be assessed for bladder/bowel dysfunction (BBD). Children who have VUR along with any BBD symptoms are at greater risk of kidney damage due to infection.
• The standard treatment for primary VUR has included prompt treatment of UTIs and long-term use of antibiotics to prevent UTIs, also called antimicrobial prophylaxis, until VUR goes away on its own. Surgery has also been used in certain cases.
• Secondary VUR is treated by removing the blockage causing the reflux.

References

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.