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Volledige samenvatting deel urologie (nier en urinewegen)

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  • Course
  • Nier en urinewegen
  • Institution
  • Katholieke Universiteit Leuven (KU Leuven)

Volledige samenvatting van het deel urologie voor het vak nier en urinewegen. Gemaakt op basis van slides en eigen lesnotities. Bevat alle te kennen leerstof voor het examen. Gedoceerd door prof. Van der Aa en prof. Everaerts.

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  • September 5, 2023
  • 66
  • 2022/2023
  • Summary

Subjects

  • nier
  • urinewegen
  • nier en urinewegen
  • nefrologie
  • urologie
  • master geneeskunde
  • geneeskunde
  • ku leuven

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  • Katholieke Universiteit Leuven (KU Leuven)
  • Geneeskunde
  • Nier en urinewegen
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UROLOGIE

INHOUDSOPGAVE

Inleiding.......................................................................................................................................................... 5
Lessen en examen ............................................................................................................................................... 5
Wat is urologie? .................................................................................................................................................. 5

H1: Lower urinary tract symptoms (LUTS) ....................................................................................................... 6
Doelstellingen ..................................................................................................................................................... 6
LUTS .................................................................................................................................................................... 6
Anamnese ........................................................................................................................................................... 6
Klinisch onderzoek ............................................................................................................................................... 7
Bijkomende onderzoeken .................................................................................................................................... 8
Mictiedagboek ................................................................................................................................................ 8
Urineonderzoek .............................................................................................................................................. 8
Bloedname...................................................................................................................................................... 8
Urofluwmetrie/urodynamisch onderzoek ...................................................................................................... 9
Beeldvorming.................................................................................................................................................. 9
Specifieke ziektebeelden van LUTS ...................................................................................................................... 9
Overactief blaaslijden met/zonder urge incontinentie .................................................................................. 9
Neurogene blaas ........................................................................................................................................... 10
Stress incontinentie ...................................................................................................................................... 11
Continue incontintie (overloop – fistels) ...................................................................................................... 12
Overloop incontinentie ............................................................................................................................ 12
Vesicovaginale fistel ................................................................................................................................. 12
! Mannelijke LUTS ......................................................................................................................................... 13
Beninge prostaathyperplasie ................................................................................................................... 13
Andere oorzaken en behandelingen ........................................................................................................ 16

H2: Penoscrotale afwijkingen ........................................................................................................................ 18
Scrotale aandoeningen ..................................................................................................................................... 18
Inleiding ........................................................................................................................................................ 18
Anatomie van het scrotum ....................................................................................................................... 18
Functie testis en epididymis ..................................................................................................................... 19
Mogelijke klachten ................................................................................................................................... 19
Scrotale pathologie .................................................................................................................................. 19
Differentieel diagnoses scrotale zwelling ................................................................................................. 19
Goedaardige oorzaken van pijnloze scrotale zwelling .................................................................................. 20
Hydrocoele ............................................................................................................................................... 20
Liesbreuk .................................................................................................................................................. 21
Spermatocoele/ epididymiscyste ............................................................................................................. 21
Varicocoele ............................................................................................................................................... 21
Afwijkingen scrotale huid ......................................................................................................................... 22
Testistumoren............................................................................................................................................... 22



1

, Pijnlijke scrotale zwelling .............................................................................................................................. 24
Torsio testis .............................................................................................................................................. 24
Torsio appendix testis .............................................................................................................................. 25
Acute epididymitis/ epididimo-orchitis .................................................................................................... 25
Gangreen van Fourier............................................................................................................................... 26
Trauma testis ............................................................................................................................................ 26
Indalingsstoornissen van de testis ................................................................................................................ 26
Cryptorchidie ............................................................................................................................................ 27
Peniele aandoeningen ....................................................................................................................................... 27
Kind ............................................................................................................................................................... 27
Voorhuid................................................................................................................................................... 27
Balanopreputiale vergroeiingen ............................................................................................................... 27
fimosis ...................................................................................................................................................... 27
balanitis .................................................................................................................................................... 28
Circumcisio ............................................................................................................................................... 28
hypospadie ............................................................................................................................................... 28
epispadias en blaasextrofie ...................................................................................................................... 28
Volwassenen ................................................................................................................................................. 28
Fimosis...................................................................................................................................................... 28
Balanitis en postitis .................................................................................................................................. 28
Frenulum breve ........................................................................................................................................ 29
Parafimosis ............................................................................................................................................... 29
Zv La Peyronnie ........................................................................................................................................ 29
Priapisme.................................................................................................................................................. 29
Penistumoren ........................................................................................................................................... 29

H3: infecties, urolithiasis en problemen van de hogere urinewegen .............................................................. 31
Doelstellingen ................................................................................................................................................... 31
Infecties ............................................................................................................................................................. 31
Indeling ......................................................................................................................................................... 31
Cystitis .......................................................................................................................................................... 31
Ongecompliceerde cystitis ....................................................................................................................... 32
Gecompliceerde cystitis ........................................................................................................................... 32
Recidiverende cystitis ............................................................................................................................... 32
Rationeel antibioticagebruik .................................................................................................................... 32
Blaaspijnsyndroom (interstitiele cystitis) ................................................................................................. 33
Pyelonefritis .................................................................................................................................................. 33
Urosepsis ...................................................................................................................................................... 33
Pyonefrose .................................................................................................................................................... 34
Prostatitis...................................................................................................................................................... 34
Epididymo-orchitis ........................................................................................................................................ 35
Orchitis ......................................................................................................................................................... 36
Urethritis ...................................................................................................................................................... 36
Urolithiasis en problemen van hogere urinewegen .......................................................................................... 36
Pyelourethrale junctie stenose ..................................................................................................................... 36
Urethrocoele ................................................................................................................................................ 36
Vesicourethrale reflux .................................................................................................................................. 36
Nierkoliek...................................................................................................................................................... 37
Behandeling .................................................................................................................................................. 38
Behandelplan ........................................................................................................................................... 38
Acute behandeling ................................................................................................................................... 38
Therapie urolithiasis ................................................................................................................................. 38



2

, Metafylaxe: algemeen .............................................................................................................................. 39
Metabool onderzoek ................................................................................................................................ 40
Steensoorten ............................................................................................................................................ 40

H4: Blaas- en nierkanker ............................................................................................................................... 42
Hematurie ......................................................................................................................................................... 42
Soorten hematurie ....................................................................................................................................... 42
Valse hematurie ....................................................................................................................................... 42
Macroscopisch vs microscopisch.............................................................................................................. 42
Pijnlijk vs pijnloos ..................................................................................................................................... 42
Glomerulair vs extraglomerulair .............................................................................................................. 42
Timing hematurie ..................................................................................................................................... 43
Oorzaken van hematurie .............................................................................................................................. 43
Locatie ...................................................................................................................................................... 43
Pathogenese ............................................................................................................................................. 43
Technische onderzoeken .............................................................................................................................. 44
Urineonderzoek........................................................................................................................................ 44
Cystoscopie .............................................................................................................................................. 44
Echo nieren en blaas ................................................................................................................................ 44
CT-IVU ...................................................................................................................................................... 45
Blaaskanker....................................................................................................................................................... 45
Epidemiologie ............................................................................................................................................... 45
Risicofactoren ............................................................................................................................................... 45
Symptomen .................................................................................................................................................. 45
Diagnostische testen .................................................................................................................................... 45
Pathologie ..................................................................................................................................................... 46
Prognose ....................................................................................................................................................... 46
Behandeling .................................................................................................................................................. 46
TCC hogere urinewegen .................................................................................................................................... 47
Nierkanker......................................................................................................................................................... 47
Renaal cel carcinoom.................................................................................................................................... 48
Risicofactoren........................................................................................................................................... 48
Pathologie ................................................................................................................................................ 48
Symptomen .............................................................................................................................................. 48
Diagnose ................................................................................................................................................... 48
TNM classificatie ...................................................................................................................................... 48
Prognostische factoren ............................................................................................................................ 49
Behandeling.............................................................................................................................................. 49
Wilms tumor = nefroblastoom ..................................................................................................................... 49

H5: Trauma, seksuele dysfunctie bij de man, kinderurologie ......................................................................... 50
Trauma .............................................................................................................................................................. 50
Nier ............................................................................................................................................................... 50
Urether ......................................................................................................................................................... 50
Blaas ............................................................................................................................................................. 51
Urethra ......................................................................................................................................................... 51
Scrotum ........................................................................................................................................................ 52
Penisfractuur ................................................................................................................................................ 52
Seksuele dysfunctie bij de man ......................................................................................................................... 53
Erectiele dysfunctie ...................................................................................................................................... 53
Priapisme ...................................................................................................................................................... 54



3

, Premature ejaculatie .................................................................................................................................... 54
Andere ejaculatoire dysfuncties ................................................................................................................... 54
Ziekte van La Peyronie .................................................................................................................................. 54
Kinderurologie ................................................................................................................................................... 55

H6: Prostaatkanker ....................................................................................................................................... 57
Anatomie & fysiologie ....................................................................................................................................... 57
Epidemiologie.................................................................................................................................................... 57
Risicofactoren.................................................................................................................................................... 57
Evolutie van prostaat adenocarcinoma ............................................................................................................ 58
Diagnose ........................................................................................................................................................... 58
Klinische presentatie .................................................................................................................................... 58
PSA: prostaat specifiek antigen .................................................................................................................... 59
PPA ............................................................................................................................................................... 59
TRUS: transrectale ultrasound ...................................................................................................................... 59
MRI prostaat ................................................................................................................................................. 59
Prostaatbiopsies ........................................................................................................................................... 59
Screening ........................................................................................................................................................... 60
Staging en risico stratificatie............................................................................................................................. 63
Staging: TNM ................................................................................................................................................ 63
Risicostratificatie .......................................................................................................................................... 63
Behandeling: lokale therapie ............................................................................................................................ 63
Wat bepaalt de therapiekeuze? ................................................................................................................... 63
Therapieopties .............................................................................................................................................. 63
Behandeling: systeemtherapie .......................................................................................................................... 64
Hormonale therapieën ................................................................................................................................. 64
Chirurgische castratie ............................................................................................................................... 65
LHRH analogen ......................................................................................................................................... 65
Anti-androgenen ...................................................................................................................................... 65
Inhibitie testosterone synthese................................................................................................................ 65
Castratie-resistent prostaatcarcinoma ..................................................................................................... 65
ARTA: androgeen receptor targeting agents ................................................................................................ 66
Gemetastaseerd prostaatcarcinoom ............................................................................................................ 66




4

, INLEIDING

LESSEN EN EXAMEN
F. Van der Aa en W. Everaerts
Leerstof = slides
Examen: theoretische vragen en casussen, als je theoretische lessen kent, kan je het examen
Klinische lessen: casussen beter kunnen oplossen, handig voor basis klinisch redeneren

WAT IS UROLOGIE?
- = specialisatie die zich bezig houdt met aandoeningen van de nieren, urinewegen en
mannelijke geslachtsorganen
- Man en vrouw
- Snijdend, medisch en endoscopisch beroep
- Endoscopie
o Flexibele (video)cystoscopie vs rigide
o Kleine procedures: coagulatie, botoxinjectie, extractie stent of steen
RX CONTRAST ONDERZOEKEN
- Antegrade of retrograde contrast onderzoeken van urinewegen ≠ IV contrast
UROLOGISCHE INTERVENTIES: DRAINAGE LAGE URINEWEGEN: BLAASSONDE
- Juiste techniek, juiste sondekeuze
o Intermittent vs verblijf
o Transurethraal vs suprapubisch
- Verblijfssonde = belangrijke oorzaak van nosocomiale infecties (CAUTI)
o Goede indicatie
o Tijdig verwijderen
o Altijd kolonisatie van de blaas
o Kan leiden tot bloeding, verstoppingen, opstijgende infectie
UROLOGISCHE INTERVENTIES: DRAINAGE HOGE URINEWEGEN
- Belangrijk, kan levensreddend/verlengend zijn
o Fors ontstoken nier en obstructie -> risico urosepsis -> urgentie
o Drainage pyonefrose
o Drainage chronisch gestuwde nier met post-renaal nierfalen (cave DNR)
- DJ stent vs nefrostomie: bij obstructie urineleider




5

, H1: LOWER URINARY TRACT SYMPTOMS (LUTS)
Prof. Van der Aa

DOELSTELLINGEN
- Symptoomgerichte benadering van LUTS kennen
- Via grondige anamneses en ko tot DD kunnen komen
- Enkele bijkomende onderzoeken kunnen interpreteren
- Behandeling van verschillende soorten LUTS kennen
- Complicaties (h)erkennen
- Prolaps -> zie lessen gynaecologie

LUTS
- Symptoomgerichte benadering
o 1e lijn
o Behandeling en herevaluatie
o Niet bij alarmtekens/(hoge kans op) complicaties -> overschakelen naar diagnostische
benadering
§ Pijn en hematurie zijn alarmtekens -> TCC, urineweginfectie, nierkoliek,
blaassteen
- Diagnostische benadering
o Specialist
o Bijkomende onderzoeken
Lower urinary tract
- Man: blaas, prostaat, lange urethra
- Vrouw: blaas, korte urethra
Upper urinary tract: nieren en ureters

ANAMNESE
- 3 te bevragen onderdelen:
o Irritatieve klachten = vullingssymptomen = moeite met ophouden = probleem met
reservoir
§ Toegenomen mictiefrequentie overdag
§ Nycturie
§ Urge incontinentie
o Obstructieve klachten = ledigingssymptomen = moeite met plassen = probleem met
blaascontractie
§ Hesitatie
§ Onderbroken straal = intermittentie
§ Sproeien
§ Persen nodig om urinestraal op gang te laten komen
§ Eind druppelen (lange eindfase van mictie, straal neemt af tot druppelen)
o Post-mictie symptomen = klachten net na plassen
§ Gevoel dat blaas niet leeg is
§ Nadruppelen (meteen na mictie, meestal na verlaten toilet)
- LUTS volledig navragen
- Alarmsymptomen? Pijn en hematurie


6

, - Hoofdklacht afzonderen en eerst behandelen: wat is meest storende klacht?
o Duur van klachten
o Incontinentie: urge vs stress vs continue
o Pollakisurie: dag/nacht, drinkgedrag, oedemen, medicatie (vb diuretica)
o Pijn: locatie, aard, uitstraling, tijdsverloop
o Impact op dagelijks leven?
o Is de klacht van die aard dat je er medicatie wil voor nemen/HK wil ondergaan?
- Geassocieerde klachten: GI, seksueel, gynaecologisch, neurologisch …
- Korte neurologische anamnese en ko
- Symptoomscores: symptomen kwantificeren en opvolgen, aangeraden door specialistische
guidelines
TYPISCH VAN URINAIRE INCONTINENTIE
- Urgency incontinentie: progressief, over jaren
- Stress/aandrang incontinentie: vaak storender
- Gemende incontinentie: beide soorten komen soms samen voor
- Continue urineverlies/overloop

KLINISCH ONDERZOEK
- Suprapubisch palperen en percussie
- Externe genitalia inspecteren
- Perineum/ onderste ledematen
- PPA
à globus, pinpoint fimosis, prostaat afmetingen, prostaatkanker, neurologische afwijkingen
Man
- Globus: zichtbaar in onderbuik
- Liesbreuk: lies palperen
- Fimosis: glans penis bekijken
Vrouw
- Suprapubisch palperen en percussie
- Gynaecologische houding
o Externe genitalia, atrofie? -> nl bij postmenopauzale vrouwen
o Persen/hoesten: urineverlies, urethrale hypermobiliteit, verzakking
§ Urethrale hypermobiliteit
• Leidt tot stressincontinentie
• Hypermobiliteit van urethra, door verzwakt urogenitaal diafragma ->
bekkenbodemspieren kunnen urethra niet afsluiten -> incontinentie




7

, o Speculum: verzakking tegen houden
§ Rectocoele = verzakking darm
§ Cystocoele = verzakking blaas
o Bekkenbodemkracht en proprioceptie
- Perineum en onderste ledematen
o Sensibiliteit
o Littekens van operaties

BIJKOMENDE ONDERZOEKEN
- Mictiedagboek
- Urineonderzoek
- Uroflowmetrie/urodynamisch onderzoek
- Echo
- RX contrast onderzoek (iv of urinewegen)
- CT (a blanc, trifasisch)
- Endoscopie: poliklinisch vs OK
MICTIEDAGBOEK
- Vnl bij vullingssymptomen, nycturie, onduidelijke anamnese
- Frequentie, volume, 24 uurs urineproductie, vochtinname
- Verlies?, pijn?, aandrang?, activiteit?
URINEONDERZOEK
- Dipstick/microscopie -> cultuur
- Dipstick
o Nitrieten -> G-
o Screening, snel, on site
o UTI: leukocyte esterasen, nitrieten
o Lithiasis: pH
o Microscopische hematurie
o Proteïnurie, glucosurie -> zie nefro
- Microscopie: rbc: aantal en morfologie
o Morfologie normaal -> urologie
o Morfologie abnormaal -> nefrologie
- Urinecultuur
o Significante bacteriële groei
o Identificatie oorzakelijke kiem en resistentie
o I/: symptomatische urineweginfectie, niet bij ongecompliceerde cystitis
o Afname: midstream, sondage, suprapubische punctie, vers
- (Cytologie)
- VD: gemakkelijk en eenvoudig, goedkoop, brede consensus
- Geen pijn -> geen bijkomende informatie?
BLOEDNAME
- Ureum, creatinine, ionogram, PSA
- Niet routine nodig
- Bij neurogeen blaaslijden -> nierfunctie
- PSA
o Orgaan-specifiek protease -> houdt ejaculaat vloeibaar wanneer het uit het lichaam is


8

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