Transcript Urology 101 for the General Surgeon

Basic Urology for
Primary Care
Providers
Getting Yourself and Your
Patients Beyond ”Please
Hold”
Michael Jacobson MD PhD
2/12/12
My Contact Information
 Email (Preferred!!)
 [email protected]
 Pager
 (510) 231-3157
 Phone
 (510) 798-4537
Overview/Goals
Urology Referrals
Topics
 BPH & Urine Retention
 How to approach the
most common
problems
 Hematuria
 Providing a useful
workup when
consulting
 Infections of the
urinary tract
 Improved
collaboration
 Incontinence
 Elevated PSA
 Stones
Background
The Long Wait
 Nonurgent urology consult
 8-9 months
 Cancer
 6-8 weeks consult
 +8-10 weeks surgery
 Obstructive stones
 6-8 weeks
 +12 weeks surgery
 65-80 patients scheduled each
clinic
Benign Prostatic
Hypertrophy
 50% men > 60 yo
 90% men > 80 yo
 Nonmalignant, uncontrolled
prostatic growth
 Bladder Outlet Obstruction
 Lower urinary tract sx
(LUTS)
 Obstructive
 Irritative
 Hematuria
LUTS
Obstructive
Irritative
 Weak stream
 Frequency
 Intermittency
 Urgency
 Hesitancy
 Nocturia
 Incomplete voiding
 Dysuria
 Postvoid dribbling
 Straining to void
 Valsalva
LUTS Differential Diagnosis
 BPH
 UTI
 Primary bladder dysfunction (MS, neurogenic bladder,
DM)
 Prostatitis/chronic pelvic pain
 Urethral stricture
 Stones
 Prostate cancer, Bladder cancer
Helpful tip:
 Men older than 60 who
have LUTS
 USUALLY have BPH
 Men younger than 50 who
have LUTS
 ALMOST NEVER have BPH
Initial Workup
1. Digital Rectal Exam
2. UA
3. PSA (> 10 years life expectancy)
4. Post void residual (Ultrasound or bladder scanner)
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Normal < 100 mL
Over 100 mL: BPH should be treated
Goal of therapy: PVR < 100
AUA symptom score
Treatment options for BPH
 Surveillance with general measures
 AUA SS < 8
 Yearly re-evaluation with “initial workup”
 Medications
 Herbal
 Alpha blockers
 5 alpha reductase inhibitors
 Surgical
 Minimally invasive
 TURP
 Simple prostatectomy
General Measures
 Avoid substances that make symptoms worse
 Alpha agonists
 Decongestants with pseudoephedrine
 Ephedra
 Caffeine and EtOH
 Spicy and acidic foods
 Reduce nocturia:
 Decrease fluids in the evening
 Avoid diuretics in the evening
 LE edema: elevate legs one hour before bed
Medications
Alpha blockers
 Works over days
 Relaxes smooth muscle in
urethra
 5-alpha reductase
inhibitors
 Shrinks the prostate
 Good for bleeding
 Prevents/treats
obstruction
 PSA drops by 50%
 Side effects: sexual,
gynecomastica
 Works over months
Alpha Blockade
 Alpha-1 blockers (postural hypotension):
 Terazosin (eff dose: 10 mg qhs)
 Doxazosin (eff dose: 8 mg qhs)
*Always titrate alpha-1 blockers to avoid
hypotension/syncope.
 Alpha 1-a blocker
 Tamsulosin—Flomax (eff dose 0.4-0.8 mg 30 min qAC)
*No need to titrate
I recommend tamsulosin for patients in urinary retention
Surgical Therapy
 Strong indications
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Refractory urinary retention
Recurrent UTIs
Refractory gross hematuria
Bladder stones
Renal insufficiency
 Moderate indications
 AUA SS > 8 and
 Substantial bother
 Increasing PVR
Urinary Retention
 Pre-existing partial obstruction
(e.g. BPH)
 Sudden increased outlet
resistance or decreased detrusor
pressure
 Precipitating event:
 Infection
 Bleeding
 Overdistention
Treatment
Gross hematuria (clot retention, bladder
decompression bleeding), Renal failure,
febrile UTI
 Admission to hospital through ER
Most patients
 Foley Catheter for 10 days
 Start alpha blocker
 Patients in complete retention
 Start 5 alpha reductase inhibitor
Referral
 AUA SS
 What medications, doses and how long
 Cr
 PVR
 Infections, urinary retention or gross hematuria
Hematuria
Differential Diagnosis
 Cancer (painless)
 Bladder, Kidney, Prostate
 Infection
 Stones
 BPH
 Trauma
 Medications/toxins
 Benign/idiopathic
Hematuria
 Many benign causes, some malignant
 We don’t want to miss cancer
 Urgent:
 Passing clots, can’t void
 Blood loss anemia (rare)
 Not urgent:
 Able to void
 Normal H/H, normal Cr
Gross vs Microhematuria
Gross
Pink Lemonade
Cool Aid
Red Wine
Motor Oil
Ketchup
Microhematuria
 > 5 RBC per High
Power Field
 At least 2 separate
Uas
 Need microscopic,
dipstick not enough!
 Not explained by
infection
Workup—Gross Hematuria
Workup
When to send to ER
 UA/Cx (nitrite
positive?)
Dropping H/H
 CBC
Unrelenting Clot
retention
 Chem7
 CT urogram (3 phase
scan with IV contrast)
 Follow-up for
cystoscopy
Microscopic hematuria workup
 Urine culture, UA with micro x 2, CBC, chem 7
 Upper tract imaging: CT IVP (with delayed phase)
 Referral for cystoscopy
 (last part of the workup)
 For patients with elevated creatinine, refer without CT
scan
 retrograde pyelogram in the OR
 u/s or noncon might be helpful
CT IVP (CT Urogram)
 3 phases:
1. Noncontrast Abdomen/Pelvis
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Shows stones
2. Arterial Phase

Shows vascular tumors (kidneys)
3. Delayed phase
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Opacifies urinary tract
Shows filling defects (possible tumors)
CT IVP does not adequately evaluate the bladder!!
Filling Defects
Cystoscopy-tumors
Incontinence
 Stress urinary
incontinence
 Increase in abdominal
pressure
 Coughing
 Sneezing
 Straining
 Lifting
 Bending
 Exercising/exertion
 Urge urinary incontinence
 Accompanied by urge
 Mixed incontinence
 Both stress and urge
 Continuous incontinence
 e.g. secondary to fistula
 Overflow incontinence
 Associated with poor
emptying
Transient Urinary Incontinence
“DIAPPERS”
 Delirium
 Infection
 Atrophic vaginitis
 Pharmaceuticals/polypharm
 Psychological (esp.
depression)
 Excessive production
(diuretics, DM)
 Restricted Mobility (PD,
arthritis)
 Stool impaction/Constipation
“Urologic Incontinence”
What you can try for urge
incontinence first
 Anticholinergic medications
 Ditropan 5 mg po TID or Ditropan XR 10 mg po daily
 Urinary retention
 Dry mouth, dry eyes, constipation
 Delirium
 Vesicare, Detrol, etc
 For post menopausal women with no history of breast or
GYN cancer:
 Vaginal Premarin or Estrace cream
 Pea size daily x 4 weeks then 2x per week
Evaluation/include on referral:
 History
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Precipitating factors
Severity: # pads per day, how wet
Obstructive/irritative sx
OB history
Previous GU conditions
Previous pelvic surgery
Neurologic disease
Fluid consumption
Medications
Physical exam
 Pelvic exam on women
 Check for atrophic vaginitis
 Obvious prolapse
 Cough test
 Rectal exam
 Stool impaction, sphincter tone
 Lower extremities
 Edema can cause excess urine production at night
 Neurological
 Perineal sensation, anal sphincter tone
 Bulbocavernosus reflex
Infections
 Frequent urinary tract infections
 Epididymitis
 Orchitis
 Prostatitis
Frequent UTIs
 Men: Think BPH or chronic bacterial prostatitis
 Young women: Think Constipation, sexual activity
 Postmenopausal women: Think atrophic vaginitis or
constipation or both
Relapsing UTI classification
 Bacterial persistence versus re-infection
 Bacterial persistence:
 Antibiotics eradicate bacteria from the urine temporarily
 Often associated with foreign body or stone
 Urine culture showing the same bacteria repeatedly
 Evaluation
 Urine culture prior to each treatment with appropriate abx
 Renal/bladder u/s plus KUB (Stones? PVR? Hydro?)
 Check blood sugar
Treatment
 Women with afebrile UTIs
 3 days antibiotics
 Check urine culture before starting empiric treatment
 Men
 10-14 days of abx
 Check urine culture before starting empiric treatment
Epididymo-Orchitis
 Presentation
 Testicular pain (Ddx: testicular torsion)
 Sudden onset of intense pain  Torsion
 Gradual onset  epididymo-orchitis
 Associated with STD: with urethritis and urethral discharge
 May be associated with UTI
 Swelling/tenderness of testis, epididymis and/or cord
 +/- scrotal erythema or edema
 +/- fever
 +/- hydrocele
 ALL PATIENTS REQUIRE A SCROTAL ULTRASOUND
Epididymo-Orchitis--Treatment
 Infectious
 Men < 35 years old:
 STD (Neisseria gonorrhoeae and Chlamydia trachomatis)
 Treat with Rocephin 250 mg IM single dose + Doxycycline 100 mg po
BID x 10 days
 Check urine culture first
 Check urethral swab or GC urine test first
 Men > 35 years old: most common E. coli
 Initial treatment: Levofloxacin x 10 days
 Adjust according to urine culture
 Pain/fever usually improve after 3 days. Induration may take
weeks/months
 If symptoms return then treat up to 6 weeks with antibiotics
Prostatitis
 Most commonly: NONBACTERIAL
 Chronic prostate syndromes: Pain
 GU pain, back pain, suprapubic pain, perineal pain, dysuria,
frequency, urgency, painful ejaculation
 Acute Bacterial Prostatitis
 Usually diagnosed in YOUNG MEN
 Most common: E.coli
 Fever, irritative/obstructive voiding sx, extremely tender
and warm/boggy prostate
Prostatitis--continued
 Chronic Bacterial Prostatitis
 Recurrent, symptomatic infection
 GU pain, back pain, suprapubic pain, perineal pain, dysuria,
frequency/urgency, painful ejaculation
 Usually diagnosed in OLDER MEN
 Most common organism: E.Coli
 Associated with prostatic calculi (nidus)
 Most common cause of recurrent UTIs in adult males
Treatment
 Acute prostatitis
 Emergency room—especially if with high fever
 Will need 4-6 weeks of post hospitalization antibiotics
 If not hospitalized, get urine culture and start a
fluoroquinolone
 Consider tylenol, stool softeners, analgesics
 Chronic prostatitis
 8-16 weeks of initial antibiotic therapy
 Reculture if symptoms return or persists
 Recurrent: 6 months suppressive abx
Nonbacterial Prostatitis
 Treatment:
 Empiric 6-8 week course of TMP-SMX or fluoroquinolone
 If no response then doxycycline 100 mg po bid for 4-6
weeks
 If no response then no further antibiotic treatment
 Consider
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alpha blockade
Stress reduction/meditation
Diet improvement
Diazepam (pelvic floor relaxation)
Pelvic PT for pelvic floor relaxation)
Pain specialist
Prostate Cancer Screening
Prostate Cancer Screening and
Diagnosis
 PSA and DRE
 Increase in detection
 Stage shift
 Prior to screening: CaP detected when caused local
symptoms or mets
 Now: > 90% CaP detected when potentially curable
 Asymptomatic
Prostate cancer--Epidemiology
Screening Recommendations (AUA,
NCCN, ACS)
 Annual PSA and DRE
 In men with > 10 years life expectancy:
 Start 40-45 for high risk of CaP
 Start 50 other men
 >70 if healthy with >10 years life expectancy
 Prior to testing, discuss benefits and limitations of CaP
detection and treatment
Digital Rectal Exam
 Abnormal DRE
 CaP diagnosis in 15%-25%
 Normal DRE (age matched)
 <5% cancer prevalence
 Not accurate or sensitive
 But abn DRE with elevated
PSA: 5x increased risk of CaP
PSA—Prostate Specific Antigen
 Serum protease produced only
in prostate epithelium
 Causes semen to become less
viscous
 Increase in serum PSA
 Prostate cancer
 Prostatitis or UTI
 BPH
 Urinary retention
 Ejaculation
 Catheterization
Serum PSA levels
 “Normal” based on age
 40’s: less than 1 ng/dL
 50’s: less than 2.5
 60’s: less than 4
 My criteria for prostate biopsy
 40’s: >1 and increasing by 0.3/year
 50’s: > 2.5 and/or increasing by 0.3/year
 60’s: > 4. If > 4 increasing by 0.7/year, if <4 increasing by
0.3/year
 Any abnormal DRE
Stones
Flank Pain Workup
 History:
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Previous stones?
Diabetic?
Length/severity of sx?
Fevers?
Severe n/v?
 Labs:
 WBC
 sCr
 UA: nitrites?
 Exam
 Febrile?
 Helped with
narcotics/antiemetics?
 Imaging
 Hydro? (obstructive?)
 2 kidneys?
Urolithiasis
Absolute reasons for
admission/immediate tx:

Obstructed
pyelonephritis
 Increasing renal
insufficiency (e.g. Solitary
kidney, bilateral stones)
 Unrelenting pain or
nausea/vomiting
Imaging
 Gold standard: Noncontrast CT scan
 Radiation, expensive, in-demand resource
 Ultrasound?
 Quick, available, no radiation
 Not very sensitive for hydro
 Miss small stones
 Cannot be used to plan surgical treatment
 KUB
 Quick, inexpensive, lower radiation dose
 Problems: radiolucent stones, stool/poor sensitivity
Immediate referral for drainage
Sepsis
Fever with UTI (and stone) or elevated WBC
Creatinine 0.5 higher than baseline
Solitary kidney (or functionally solitary)
(Uncontrollable pain or vomiting)
Beware of the diabetic patient with UTI +
stone
 May have few sx
The passable stone
 < 4mm: >90%
 4-6 mm: 70-80%
 6-8 mm: 50-60%
 8-10 mm: ~30%
 >10 mm: unlikely
 Assuming 6 weeks, with Flomax