Basic Urology for Primary Care ProvidersGetting Yourself and Your Patients Beyond ”Please Hold”

Michael Jacobson MD PhD2/12/12

My Contact InformationEmail (Preferred!!)

mjacobson@acmedctr.org

Pager (510) 231-3157

Phone (510) 798-4537

Overview/GoalsUrology Referrals

How to approach the most common problems

Providing a useful workup when consulting

Improved collaboration

TopicsBPH & Urine RetentionHematuriaIncontinenceInfections of the

urinary tractElevated PSAStones

BackgroundThe 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 yo90% men > 80 yoNonmalignant,

uncontrolled prostatic growth Bladder Outlet

Obstruction Lower urinary tract sx

(LUTS) Obstructive Irritative

Hematuria

LUTSObstructive

Weak stream IntermittencyHesitancy Incomplete voidingPostvoid dribblingStraining to void

Valsalva

IrritativeFrequencyUrgencyNocturiaDysuria

LUTS Differential DiagnosisBPHUTIPrimary bladder dysfunction (MS, neurogenic

bladder, DM)Prostatitis/chronic pelvic painUrethral strictureStonesProstate 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 Workup1. Digital Rectal Exam2. UA3. PSA (> 10 years life expectancy)4. Post void residual (Ultrasound or bladder

scanner) Normal < 100 mL Over 100 mL: BPH should be treated Goal of therapy: PVR < 100

AUA symptom score

Treatment options for BPHSurveillance 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 MeasuresAvoid substances that make symptoms worse

Alpha agonists Decongestants with pseudoephedrine Ephedra

Caffeine and EtOHSpicy and acidic foods

Reduce nocturia:Decrease fluids in the eveningAvoid diuretics in the eveningLE edema: elevate legs one hour before bed

MedicationsAlpha blockers

Works over days Relaxes smooth muscle

in urethra

5-alpha reductase inhibitors

Shrinks the prostateGood for bleedingPrevents/treats

obstructionPSA drops by 50%Side effects: sexual,

gynecomasticaWorks over months

Alpha BlockadeAlpha-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 blockerTamsulosin—Flomax (eff dose 0.4-0.8 mg 30 min

qAC)*No need to titrateI recommend tamsulosin for patients in urinary

retention

Surgical TherapyStrong indications

Refractory urinary retentionRecurrent UTIsRefractory gross hematuriaBladder stonesRenal insufficiency

Moderate indicationsAUA 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

TreatmentGross hematuria (clot retention, bladder

decompression bleeding), Renal failure, febrile UTI

Admission to hospital through ERMost patients

Foley Catheter for 10 daysStart alpha blocker Patients in complete retention

Start 5 alpha reductase inhibitor

ReferralAUA SSWhat medications, doses and how longCrPVRInfections, urinary retention or gross hematuria

Hematuria Differential Diagnosis

Cancer (painless) Bladder, Kidney, Prostate

Infection

Stones

BPH

Trauma

Medications/toxins

Benign/idiopathic

HematuriaMany benign causes, some malignantWe don’t want to miss cancerUrgent:

Passing clots, can’t voidBlood loss anemia (rare)

Not urgent:Able to void

Normal H/H, normal Cr

Gross vs MicrohematuriaGross

Pink LemonadeCool AidRed WineMotor OilKetchup

Microhematuria> 5 RBC per High

Power FieldAt least 2

separate UasNeed microscopic,

dipstick not enough!

Not explained by infection

Workup—Gross HematuriaWorkup

UA/Cx (nitrite positive?)

CBCChem7CT urogram (3

phase scan with IV contrast)

Follow-up for cystoscopy

When to send to ER

Dropping H/HUnrelenting

Clot retention

Microscopic hematuria workupUrine culture, UA with micro x 2, CBC, chem 7Upper 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 ORu/s or noncon might be helpful

CT IVP (CT Urogram)3 phases:1. Noncontrast Abdomen/Pelvis

Shows stones

2. Arterial Phase Shows vascular tumors (kidneys)

3. Delayed phase Opacifies urinary tract Shows filling defects (possible tumors)

CT IVP does not adequately evaluate the bladder!!

Filling Defects

Cystoscopy-tumors

IncontinenceStress urinary

incontinence Increase in

abdominal pressureCoughingSneezingStrainingLiftingBendingExercising/

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 firstAnticholinergic 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

Precipitating factorsSeverity: # pads per day, how

wetObstructive/irritative sxOB historyPrevious GU conditionsPrevious pelvic surgeryNeurologic diseaseFluid consumptionMedications

Physical examPelvic 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

InfectionsFrequent urinary tract infectionsEpididymitisOrchitisProstatitis

Frequent UTIsMen: Think BPH or chronic bacterial prostatitisYoung women: Think Constipation, sexual activityPostmenopausal women: Think atrophic vaginitis

or constipation or both

Relapsing UTI classificationBacterial persistence versus re-infectionBacterial persistence:

Antibiotics eradicate bacteria from the urine temporarilyOften associated with foreign body or stoneUrine culture showing the same bacteria repeatedly

EvaluationUrine culture prior to each treatment with appropriate abxRenal/bladder u/s plus KUB (Stones? PVR? Hydro?)Check blood sugar

TreatmentWomen with afebrile UTIs

3 days antibioticsCheck urine culture before starting empiric

treatmentMen

10-14 days of abxCheck urine culture before starting empiric

treatment

Epididymo-OrchitisPresentation

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 UTISwelling/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

ProstatitisMost commonly: NONBACTERIAL

Chronic prostate syndromes: Pain GU pain, back pain, suprapubic pain, perineal pain,

dysuria, frequency, urgency, painful ejaculation

Acute Bacterial ProstatitisUsually diagnosed in YOUNG MENMost common: E.coliFever, irritative/obstructive voiding sx, extremely

tender and warm/boggy prostate

Prostatitis--continuedChronic 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.ColiAssociated with prostatic calculi (nidus)Most common cause of recurrent UTIs in adult

males

TreatmentAcute prostatitis

Emergency room—especially if with high feverWill need 4-6 weeks of post hospitalization

antibiotics If not hospitalized, get urine culture and start a

fluoroquinoloneConsider tylenol, stool softeners, analgesics

Chronic prostatitis8-16 weeks of initial antibiotic therapyReculture if symptoms return or persistsRecurrent: 6 months suppressive abx

Nonbacterial ProstatitisTreatment:

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 treatmentConsider

alpha blockade Stress reduction/meditation Diet improvement Diazepam (pelvic floor relaxation) Pelvic PT for pelvic floor relaxation) Pain specialist

Prostate Cancer Screening

PSA and DRE Increase in detectionStage shiftPrior to screening: CaP detected when caused local

symptoms or metsNow: > 90% CaP detected when potentially curable

Asymptomatic

Prostate Cancer Screening and Diagnosis

Prostate cancer--Epidemiology

Annual PSA and DREIn men with > 10 years life expectancy:

Start 40-45 for high risk of CaPStart 50 other men>70 if healthy with >10 years life expectancy

Prior to testing, discuss benefits and limitations of CaP detection and treatment

Screening Recommendations (AUA, NCCN, ACS)

Digital Rectal ExamAbnormal 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

“Normal” based on age40’s: less than 1 ng/dL50’s: less than 2.560’s: less than 4

My criteria for prostate biopsy40’s: >1 and increasing by 0.3/year50’s: > 2.5 and/or increasing by 0.3/year60’s: > 4. If > 4 increasing by 0.7/year, if <4 increasing

by 0.3/yearAny abnormal DRE

Serum PSA levels

Stones

Flank Pain WorkupHistory:

Previous stones?Diabetic?Length/severity of sx?Fevers?Severe n/v?

Labs:WBC sCrUA: nitrites?

ExamFebrile?Helped with

narcotics/antiemetics?

ImagingHydro? (obstructive?)2 kidneys?

UrolithiasisAbsolute reasons for admission/immediate tx:

Obstructed pyelonephritis

Increasing renal insufficiency (e.g. Solitary kidney, bilateral stones)

Unrelenting pain or nausea/vomiting

ImagingGold standard: Noncontrast CT scan

Radiation, expensive, in-demand resource

Ultrasound?Quick, available, no radiationNot very sensitive for hydroMiss small stonesCannot be used to plan surgical treatment

KUBQuick, inexpensive, lower radiation doseProblems: radiolucent stones, stool/poor

sensitivity

Immediate referral for drainageSepsisFever with UTI (and stone) or elevated

WBCCreatinine 0.5 higher than baselineSolitary kidney (or functionally solitary)(Uncontrollable pain or vomiting)Beware of the diabetic patient with UTI

+ stoneMay have few sx

The passable stone< 4mm: >90%4-6 mm: 70-80%6-8 mm: 50-60%8-10 mm: ~30%>10 mm: unlikelyAssuming 6 weeks, with Flomax