Urology for the non-Urologist

Objectives

• To review common urologic conditions that present in the primary care (and urology) setting

• To discuss the evaluation of several common urologic diagnoses, the pre-Urology workup, and subsequent referral

• To discuss the management of common urologic conditions

Topics

• Microhematuria

• BPH (aka LUTS)

• Infertility

Topics

• Elevated PSA

• Stones

• Erectile dysfunction

Extras(Time permitting)

• Urologic emergencies

• Pediatric Urology

• Urology in the pregnant patient

• Urology in the hospitalized or post-op patient

Microhematuria

• Definition– Dipstick– Microscopy

• Etiology

Microhematuria

Renal (nonglomerular) Renal cell carcinoma Transitional cell carcinoma Nephrolithiasis Renal infarction Renal vein thrombosis Arteriovenous malformations Papillary necrosis Pyelonephritis Sickle cell disease Medullary sponge kidney Polycystic disease Hydronephrosis Ureteropelvic junction obstruction Renal (glomerular) IgA nephropathy Thin glomerular basement membrane disease Acute glomerulonephritis Lupus nephritis Hereditary nephritis (Alport's syndrome) Lower urinary tract

Interstitial cystitis Bacterial cystitis Radiation-induced cystitis Bladder diverticulum Bladder papilloma Bladder stone Prostate cancer Prostatitis Benign prostatic hyperplasia Bladder neck contracture Epididymitis Urethritis Urethral stricture disease Miscellaneous Strenuous exercise Excessive anticoagulation Genitourinary tuberculosis Genitourinary trauma Abdominal aortic aneurysm Lymphoma Multiple myeloma

Microhematuria

• Risk factors– Cigarette smoking – Occupational exposure (benzene, aromatic amines) – Age greater than 40 years – Previous urologic history – Urinary tract infection – Analgesic abuse – Irritative voiding – Pelvic irradiation – Cyclophosphamide

Microhematuria

• Work-up pre-Urology

– Two of three microscopic urines with at least 3-5 RBCs/hpf

– Negative urine culture – especially in symptomatic patient• If low risk and hematuria clears with abx, referral not required

– If stone considered noncontrast CT

Microhematuria• Work-up pre-Urology

– High risk patient = smoker

– Obtain upper tract imaging

• Hematuria protocol CT (normal Cr Cl and no dye allergy)

• Renal US (reduced Cr Cl, existing CRI)

– Ordered along with the Urology consult

• +/- Voided urine cytology

Gray-Sears CL, Ward JF, Sears ST, Puckett MF, Kane CJ, Amling CL. Prospective comparison of computerized tomography and excretory urography in the initial evaluation of asymptomatic hematuria. J Urol 2002;168:2457-60

Microhematuria

Microhematuria• Follow-up

– 8-12% of cases, no cause of microhematuria revealed

– 1-3% of asymptomatic microhematuria go onto dx of urologic malignancy, typically in < 3 yrs

– Repeat UA, voided cytology (and BP measurement) annually

– If smoker, strong consideration to repeat full anatomic eval

– If gross hematuria, new urinary symptoms, or (+) cytology send back to Urology

BPH

• Benign Prostatic Hyperplasia– prostatism

• Lower Urinary Tract Symptoms (LUTS)

– Obstructive

– Irritative

BPH

• Lower Urinary Tract Symptoms (LUTS)

– Obstructive• Weak stream• Intermittency• Straining• Incomplete emptying

– Irritative• Frequency• Urgency• Nocturia

BPH• Medical management

• Alpha blockers– Reduce prostatic smooth muscle tension

– Non-selective • Terazosin (Hytrin)• Doxazosin (Cardura) • Prazosin (Minipres)

– Selective• Tamsulosin (Flomax)• Alfuzosin (Uroxatral)

BPH• Medical management

• 5α-reductase inhibitors– Reduction of glandular tissue volume– Must have serum PSA drawn

– Finasteride (Proscar)

– Dutasteride (Avodart)

BPH• Combination therapy

– MTOPS study (N Engl J Med 2003; 349: 285)

• Reduction in episodes of AUR• Reduction in progression to surgical intervention

• Phytotherapy– Saw Palmetto

• Improvement in both symptom score and flowrate

BPH• Urology referral

– < 40 yo

– Symptoms despite medical therapy (trial of alpha blocker)

– Consideration for combination therapy

– Progression of symptoms while on medical therapy

– Desire to be off medication

BPH• Surgical management

– TURP, HoLEP, HoLAP, Greenlight, PVP, open prostatectomy

• Absolute Indications– Urinary retention– Recurrent infection– Recurrent hematuria– Bladder calculus– Obstructive uropathy

• Most common indication?

Infertility• Definition

• Male factor

Infertility• Evaluation

– Physical exam• Varicocele

– Semen analysis• At least two or three – separated by 1 month

– Hormone• Testosterone• FSH

• These can be ordered with the Urology consult

Infertility• Semen analysis

– The World Health Organization (1999) defines the following reference values:

• Volume: 2.0 ml or more pH: 7.2 or more Sperm concentration: 20 million or more sperm/ml (density)

Total sperm number: 40 million or more spermatozoa per ejaculate Motility: 50% or more with progressive or active motility Morphology: 15% or more by strict criteria Viability: 75% or more of sperm viable

White blood cells: Less than 1 million/ml

Elevated PSA• Screening

– High risk (+ Family Hx, African American) – age 40– All others – age 50

• Etiology– Prostate inflammation

• Do not check PSA if UTI, prostatitis, or Foley

– BPH

– Prostate Cancer

Elevated PSA

Elevated PSA

Elevated PSA

Elevated PSA• Urology referral

– Abnormal DRE• If any concern or doubt, please send

– PSA levels – nothing hard and fast BUT SAFE• 40yo: > 2.5• 50yo: > 3.5• 60yo: > 4• 70yo: > 4.5-5• 80yo: ? Should we even be checking?

– PSA velocity > 0.75 ng/ml/yr

Elevated PSA

• Other tools

– PSA density• Requires TRUS volume

– Free:Total PSA• Especially valuable for PSA in 4 to 10 ng/ml range• More of a tool for the Urologist deciding on biopsy

Nephrolithiasis• Urolithiasis

• Presentation– Flank pain LQ abd groin testicles/labia– Hematuria: gross or micro– Often hx of stones

• Imaging– KUB– Renal US– Noncontrast CT

Ureteral stone and colic• Acute ureteral colic

– NCCT study of choice

• Secondary signs of ureteral obstruction

– Hydroureter

– Unilateral hydronephrosis

– Unilateral stranding of perinephric fat

– Unilateral nephromegaly

Stone protocol CT

Stone protocol CT

Ureteral stone and colic• Urology referral - ROUTINE

– All new stones can be seen

– Pain controlled with analgesics (PO or IV)• Use Toradol – more effective than narcotic

– No UTI• Use pyuria, LE, and nitrite

– No fever

Ureteral stone and colic• Urology consult - Urgent

– Calculus with obstruction and infection• This kidney is now an abcess

– Pain not controlled with analgesics (IV)

– Nausea/vomiting precluding outpatient oral analgesics

– Febrile

– ** Diabetic**

Ureteral stone and colic• Urology consult - Urgent

• Management

– Admission for observation

– IV abx

– Intervention• Cystoscopy/stent• Percutaneous nephrostomy

Erectile dysfunction• Incidence

– > 50% of men > 60 yo

• Etiology

– Organic is typically microvascular• HTN, DM, hyperlipidemia, smoking

– Young: consider psychogenic• Ask about AM or nocturnal erections – if it works at night, should work during the

day

– Venous leak: rare

Erectile dysfunction• Before treatment

– “a man with ED and no cardiac symptoms is a cardiac (or vascular) patient until proven

otherwise.”

• Trial of PDE-5 inhibitor• Urologist should not be the Levitra doctor• Levitra failure - options include:

– Viagra, Cialis– Intraurethral topical (MUSE)– Intracavernosal injection – Vacuum erection device w/ venous constriction

Jackson, G, et al. The second Princeton consensus on sexual dysfunction and cardiac risk: new guidelines for sexual medicine. J Sex Med. 2006 Jan;3(1):28-36; discussion 36.

Urologic Emergencies• Priapism

• Testicular torsion

• Paraphimosis

• Obstructing ureteral stone with infection– Discussed

Urologic Emergencies• Priapism

– An erection lasting longer than 4 hrs that is not associated with sexual stimulation

– Considered an emergency due to potential irreversible penile ischemia, necrosis, and scarring of erectile tissue

– 50% idiopathic

– Intracavernosal injection (ICI) is most common cause in adults

– What is a common cause in children?

Urologic Emergencies• Priapism

• Management– Aspiration: 19 or 21gauge butterfly

needle• 10ml blood at a time inject

500mcg phenylephrine

– Irrigate with phenylephrine• 1 ml of 10mg/ml phenylephrine in 19

ml normal saline• Inject 500mcg every 5 min until

detumescence• Cardiac monitor/close observation• Can perform for 1 hr

Urologic Emergencies• Testicular torsion

– If you think it, please call

• Presentation– Abrupt onset testicular pain– Often, associated N/V

• Diagnosis– Exam: high-riding testicle; transverse lie; absent cremaster; swollen or firm

testis– Call Urologist– Obtain an ultrasound, SPECIFICALLY NEED DOPLER - waveforms

Urologic Emergencies• Testicular torsion

– If you think it, please call

• Management– “Open the book” – may require 2 to 3 or more turns

– What is average torsion (in degrees)? • > 360

– T/F: Manual detorsion eliminates the need for Urology consult• False: patient needs to go to OR for exploration and testis fixation

Urologic Emergencies

• Paraphimosis

Urologic Emergencies

Pediatric Urology

• Febrile UTI

– All should be worked up

– Renal/Bladder US and VCUG

– Normal eval: referral not required

– If uncircumcised boy, consider referral for circ if recurrent UTI

Pediatric Urology

• Undescended testicle (UDT)

– Referral early – goal is orchidopexy by 1 yo

– What is the most sensitive diagnostic tool for UDT?a) Ultrasoundb) CTc) MRId) Pediatric Urologist

Urology in Pregnancy

• Hydronephrosis

– Physiologic

• Symptomatic may represent obstruction/stone

– Incidence of stones no higher in pregnancy

– But…more likely in known stone former• Hypercalciuric state

Urology in Pregnancy

• Symptomatic hydronephrosis– Concern for stone

– Management: ureteral stent placement

• Stays in remainder of pregnancy

• Change every 6 weeks

Urology in Pregnancy• Prenatal hydronephrosis

• Reasonable to refer during pregancy for counseling– Not required

• Neonatal evaluation

– Renal/Bladder US at birth

– Repeat Renal/Bladder US approx 1 month

Urology in Pregnancy Pediatrics

• What is the most common cause of abdominal mass in a newborn?

Urology in Pregnancy Pediatrics

• Hydronephrosis

Urology in the Hospitalized or Post-op Patient

• Gross hematuria– Go big, or go home– Use at least 20 Fr Foley – 16 Fr will promptly get obstructed– Even better place 3-way

• Missed due-to-void– Bladder scan first

• If <200, can extend 2 hrs• If >300 or symptomatic, cath with a Foley – if > 400, leave Foley

– At least 72hrs in older men– Exception: young pt w/o reason for retention other than anesthesia

Questions?

Thank You