Basic Urology for Primary Care ProvidersGetting Yourself and Your Patients Beyond ”Please Hold”
Michael Jacobson MD PhD2/12/12
My Contact InformationEmail (Preferred!!)
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