Workshop : Managing Urinary Stones and BPH Tuckey... · How common are they? lifetime risk 15% men,...
Transcript of Workshop : Managing Urinary Stones and BPH Tuckey... · How common are they? lifetime risk 15% men,...
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Workshop : Managing Urinary Stones and BPH
Dr John Tuckey
Urologist
Auckland
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Kidney Stones
Well Mr. Osborne, it may not be kidney stones after all.
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Urinary Stones
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How common are they?
lifetime risk 15% men, 6% women
males 2.3:1
105 new stones /100,000
peak age incidence 30-50
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How common are they?
1/3 renal – often haematuria
2/3 ureteric – usually pain
1/3 have previously had a stone
20% have a family history
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How do they present?
Loin or loin to groin pain
Typically colicky, patient cannot get comfortable
beware – older patient – AAA - distal stones – irritative without pain
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Investigation
MSU - microhaematuria 10% no RBC’s
Blood Ca Hyperparathyroidism Urate Uric acid stones Nidus for Ca stones Creatinine
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Diagnosis – Plain X ray
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Intravenous Urogram - IVU
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Ultrasound
Accuracy around 80%
Ureteric stones can be missed
Best for follow-up or recurrent stone formers
Hydronephrosis infers a PUJ/ureteric stone
Ureteric jet
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CT Urogram (C-)
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CT Urogram (C-)
accuracy around 99%
quick
best for ureteric stones
size and position of stones
anatomic detail for renal stones
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CT Urogram (C-)
associated pathology
low dose protocols – accuracy vs dose
other MRI – stones not visible
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Natural History
ureteric stones - 80-90% <5mm pass - usually 1-3 weeks - remove at 6 weeks
renal stones - unlikely to pass
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Management
Refer if - ureteric stones 6mm or larger - ongoing pain - renal impairment - infection - pregnant - renal stones (outpatient)
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Management
Fluid intake
Medication - if creatinine normal
Diclofenac 75 mg - ureteric smooth muscle relaxation alpha blockers ca antagonists
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Expulsive Therapy-Alpha blockers
chance of passing - Doxazosin 38%-70% - Tamsulosin 57%-88%
time to passing - Tamsulosin 7vs12 days
analgesia - 0.14 vs 2.78 vials
which alpha blocker?
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Follow-up
KUB
Radiolucent Radio-opaque
Radiolucent
Dissolution
Ural QID, ph>6.5
Distal 90%
Proximal 50%
CT 4 wks KUB 4 wks
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What are the options if medical management fails?
Ureteric Stent
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Ureteric stents
protect kidney, prevent obstruction
stent pain an issue
symptoms improve with alpha blockers anticholinergics
remove if no improvement
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What are the options if medical management fails?
Mid and lower ureter rigid ureteroscopy
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What are the options if medical management fails?
Upper Ureter and Kidney Flexible Ureteroscopy Lithotripsy
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Flexible Ureteroscopy
Upper Ureter and Kidney
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Flexible Ureteroscopy
Lasering stones
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Flexible Ureteroscopy
Basketing Stones
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Flexible Ureteroscopy
Basketing Stones
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Extracorporeal Shock Wave Lithotripsy (ESWL)
Acoustic waves
Dornier aircraft manufacturer
Prototype 1980, first HM3 1984
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The original Lithotripter
HM3 American trials - solitary renal calculi - < 1 cm - success 77-90 %
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Shock Wave Generation
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How does ESWL work?
Dynamic fracture - compression wave - tensile tail
Erosion - cavitation
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Cavitation
Bubble cluster collapse - filled with vapour - powerful water jet - can pit metals
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Surgical options
ESWL - success 70 %, day stay
Flexi - success 90-95%, day or 1 night stay
PCNL - success 90-95%, 3-4 nights
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Surgical options
Stone position
Ureter Kidney
No pain ESWL Pain - Ureteroscopy Single
<1.5 cm ESWL
Multiple
<3cm Flexi
Kidney
Flexi or PCNL
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Stone Prevention
50% develop another stone within 10 yrs
Reduce to 20% with lifestyle/medication
GP’s ideally placed
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Why do stones form?
Solubility product: concentration in pure solution at which
crystallisation begins
Stone inhibitors
Stone promoters
Temperature, pH
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Fluid
most common problem
most important factor
aim for clear urine or 2 litres output
compliance an issue
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Is diet relevant?
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Dietary Changes
calcium - intake inversely related to risk - 2+ servings per day
oxalate - 15x more potent than calcium - nuts, spinach, chocolate, taro, rhubarb
citrate - 1 lemon/day
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Dietary Changes
salt - increases calcium excretion - healthy heart advice
protein - increased uric acid, oxalate - acid buffering in bone increased calcium excretion - 100g / day
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Medication
Allopurinol - hyperuricaemia - hyperuricosuria
Thiazides - hypercalciuria
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Recurrent stone formers
24 hour urines give more detail about risks - commonest findings low fluid intake high calcium excretion
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Recurrent stone formers
24 hour urines - normal diet and fluid intake - results can vary – 6 is best - two as a compromise
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Recurrent stone formers
24 hour urines Acid Ca, PO4, Citrate, Oxalate Non-acid uric acid , sodium
if abnormal refer to a Urologist with an interest
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Stone Prevention Summary
50% chance of more at 10 years
urine output over 2 L per day (clear urine)
moderate calcium intake
reduced dietary oxalate, meat, sodium
citric acid – juice of 1 lemon / day
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Stone Prevention Summary
monitor fluid/diet at yearly wellbeing check
imaging at 1 year
imaging periodically thereafter
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Benign Prostatic Hyperplasia
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BPH
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BPH
Transition zone increases in size with age
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Prostate and Age
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BPH
50% of histological BPH have benign enlargement
50% of benign enlargement have symptoms
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Prevalence of LUTS and Age
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Can BPH be prevented?
Age Androgens Genetic Growth factors Inflammation, Ischaemia, Nitric oxide
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Can it be prevented?
Metabolic syndrome is associated with BPH
- fasting glucose - diabetes - BMI
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Prostatism?
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Lower Urinary Tract Symptoms
aetiology could be bladder/prostate/urethra
they are not sex-specific
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Lower Urinary Tract Symptoms
look at the pattern to obtain a likely diagnosis
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LUTS
voiding symptoms due to urethral narrowing - reduced flow, hesitancy, emptying
storage symptoms are most annoying - over active bladder or obstruction - frequency, urgency, incontinence nocturia
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Natural History
symptoms wax and wane
Same 47%
Improvred
Surgery 9%
Improved 29%
Worse 15%
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Natural History
prostate growth 1-2g per year (age, PSA)
retention 0.5-2.0% over 4 years
risk increases with age 70+ PSA >4 volume >40g slower flow <12mls/sec
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PSA and Complications
cumulative incidence of retention or surgery
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History
the bladder is an unreliable witness
listen to the partner
men understate their symptoms
patients may not notice gradual changes
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History
Nocturnal enuresis is pathognomonic for chronic retention
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History
beware haematuria /pain
abrupt ending of flow
dysuria or infections
difficulty voiding particularly with alcohol
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History
Fluid intake - ask volume and type
Constipation may affect symptoms
Past History - STD - strictures - surgery - diabetes, cancer
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History
Medications - anticholinergics
Family history - 1st degree relative 2-4 risk of TURP
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Examination
Abdomen - often unrewarding
Genetalia - meatal stricture
Prostate - BPH (thenar emminence) - Ca (knuckle) - anal tone and sensation
Ankles - oedema nocturia
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Examination
Prostate - 2 fingers - 40g
- 3 fingers - 60g - 4 fingers - 100g
If you don’t put your finger in, you will put your foot in
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Is prostate size important?
Prostate - small glands can cause problems
- bladder neck rather than prostate - long history - usually use cubicles - respond well to alpha blockers
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Investigation
MSU
Creatinine
PSA
Ultrasound not required
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Fluid Balance Chart
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IPSS
does not diagnose BPH
increases with age
basis for management score <8 fluid score 8+ fluid+meds
measuring response
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Management
IPSS <8 fluid management
IPSS 8+ fluid management alpha-blockers finasteride
anticholinergics phytotherapy
Surgery failed medical management or complications
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Fluid management
volume
timing
type of fluid - caffeine, alcohol, diuretics
can make a difference
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BPH - Alpha-blockers
Alpha 1 a prostate b blood d bladder
act on smooth muscle, spinal cord, afferent
do not relieve obstruction
do not improve residuals
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BPH - Alpha-blockers
No difference in symptoms or flow rates
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BPH - Alpha-blockers
Doxazosin - 50-70% respond - 30-50% reduction in symptoms
- first dose effect - titrate from 1 – 8 mg
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BPH - Alpha-blockers
Doxazosin - side effects 10-20%
- lightheadedness - palpitations - nasal congestion
failure - trial Terazosin or Tamsulosin
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BPH - Alpha-blockers
Tamsulosin - selective , 0.4 mg daily
- fewer CVS side effects
- higher anejaculation (SV,VAS) - floppy iris syndrome - special authority
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BPH - Alpha-blockers
benefit is independent of prostate size
efficacy is similar for all agents
retention -increases chance of voiding by 30%
more effective than 5 alpha reductase inhibitors
in the short term
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5 alpha reductase inhibitors
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5 alpha reductase inhibitors
Improves IPSS by 3-4 points
reduces prostate volume - 30% over 6 months
reduces PSA by 50% - double to give true PSA
no change to PSA ratios
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5 alpha reductase inhibitors
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5 alpha reductase inhibitors
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5 alpha reductase inhibitors
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5 alpha reductase inhibitors
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5 alpha reductase inhibitors
reduces the chance of surgery and retention
reduces symptom progression
long term probably more important than alpha blockers
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Anticholinergics
overactive bladder common in obstruction
only storage symptoms - overactive bladder
may increase residual urine –check <200mls
minimal chance of retention – around 1%
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Anticholinergics
oxybutynin 5mg bd or tds
side effects trial Vesicare at 5mg - 5 mg may be better than 10 mg daily
overall combination treatment may work well
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Nitric oxide
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PDE-5 inhibitors
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Saw Palmetto
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Saw Palmetto
JAMA 369 pts RCT 72 weeks Placebo Saw Palmetto IPSS pre 14.7 14.4 IPSS post 11.7 12.2 Change -3 -2.2
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Medications Summary
alpha blockers best for <40g
combine with 5-AR best for >40g
anticholinergics helpful – beware residual
5-AR useful long term
monitor higher PSA, larger glands, older
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When to refer
bothersome symptoms
complications - retention - recurrent infections - bleeding - bladder stones - pain - incontinence - unresponsive
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