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

Michael Jacobson MD PhD

2/12/12

My Contact Information

Email (Preferred!!) mjacobson@acmedctr.or

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Pager (510) 231-3157

Phone (510) 798-4537

Overview/Goals

Urology Referrals

How to approach the most common problems

Providing a useful workup when consulting

Improved collaboration

Topics

BPH & Urine Retention

Hematuria

Incontinence

Infections of the urinary tract

Elevated PSA

Stones

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 yo

90% men > 80 yo

Nonmalignant, uncontrolled prostatic growth Bladder Outlet

Obstruction Lower urinary tract sx

(LUTS) Obstructive Irritative

Hematuria

LUTS

ObstructiveWeak stream

Intermittency

Hesitancy

Incomplete voiding

Postvoid dribbling

Straining to void Valsalva

IrritativeFrequency

Urgency

Nocturia

Dysuria

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)

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 worseAlpha 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

Medications

Alpha blockers

Works over days

Relaxes smooth muscle in urethra

5-alpha reductase inhibitors

Shrinks the prostateGood for bleedingPrevents/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 blockerTamsulosin—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 indicationsRefractory 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

Treatment

Gross hematuria (clot retention, bladder decompression bleeding), Renal failure, febrile UTI

Admission to hospital through ER

Most patientsFoley Catheter for 10 daysStart 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 voidBlood loss anemia (rare)

Not urgent:Able to void

Normal H/H, normal Cr

Gross vs Microhematuria

GrossPink 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 Hematuria

Workup

UA/Cx (nitrite positive?)

CBC

Chem7

CT urogram (3 phase scan with IV contrast)

Follow-up for cystoscopy

When to send to ER

Dropping H/H

Unrelenting Clot retention

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 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

Incontinence

Stress 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 first

Anticholinergic medicationsDitropan 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:

HistoryPrecipitating factorsSeverity: # pads per day, how

wetObstructive/irritative sxOB historyPrevious GU conditionsPrevious pelvic surgeryNeurologic diseaseFluid consumptionMedications

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 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

Treatment

Women with afebrile UTIs3 days antibioticsCheck urine culture before starting empiric

treatment

Men10-14 days of abxCheck urine culture before starting empiric

treatment

Epididymo-Orchitis

PresentationTesticular 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

Prostatitis

Most commonly: NONBACTERIALChronic 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--continued

Chronic Bacterial ProstatitisRecurrent, 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

Treatment

Acute prostatitisEmergency 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 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 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 DRE

In 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 Workup

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

Labs:WBC sCrUA: nitrites?

ExamFebrile?Helped with

narcotics/antiemetics?

ImagingHydro? (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 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 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 + 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: unlikely

Assuming 6 weeks, with Flomax