Urology for the non-Urologist

1. Urology for the non-Urologist

2. 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

3. Topics • Microhematuria • BPH (aka LUTS) • Infertility

4. Topics • Elevated PSA • Stones • Erectile dysfunction

5. Extras(Time permitting) • Urologic emergencies • Pediatric Urology • Urology in the pregnant patient • Urology in the hospitalized or post-op patient

6. Microhematuria • Definition • Dipstick • Microscopy • Etiology

7. 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

8. 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

9. 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

10. 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

11. Microhematuria

12. 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

13. BPH • Benign Prostatic Hyperplasia • prostatism • Lower Urinary Tract Symptoms (LUTS) • Obstructive • Irritative

15. BPH • Lower Urinary Tract Symptoms (LUTS) • Obstructive • Weak stream • Intermittency • Straining • Incomplete emptying • Irritative • Frequency • Urgency • Nocturia

16. BPH • Medical management • Alpha blockers • Reduce prostatic smooth muscle tension • Non-selective • Terazosin (Hytrin) • Doxazosin (Cardura) • Prazosin (Minipres) • Selective • Tamsulosin (Flomax) • Alfuzosin (Uroxatral)

17. BPH • Medical management • 5α-reductase inhibitors • Reduction of glandular tissue volume • Must have serum PSA drawn • Finasteride (Proscar) • Dutasteride (Avodart)

18. 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

19. 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

20. 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?

21. Infertility • Definition • Male factor

22. 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

23. Infertility • Semen analysis • The World Health Organization (1999) defines the followingreference 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

25. 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

26. Elevated PSA

27. Elevated PSA

28. Elevated PSA

29. 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

30. 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

32. Nephrolithiasis • Urolithiasis • Presentation • Flank pain  LQ abd  groin  testicles/labia • Hematuria: gross or micro • Often hx of stones • Imaging • KUB • Renal US • Noncontrast CT

33. 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

34. Stone protocol CT

35. Stone protocol CT

36. 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

37. 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**

38. Ureteral stone and colic • Urology consult - Urgent • Management • Admission for observation • IV abx • Intervention • Cystoscopy/stent • Percutaneous nephrostomy

39. 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

40. 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.

41. Urologic Emergencies • Priapism • Testicular torsion • Paraphimosis • Obstructing ureteral stone with infection • Discussed

42. 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?

43. 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

44. 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

45. 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

46. Urologic Emergencies • Paraphimosis

47. Urologic Emergencies

48. 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

49. Pediatric Urology • Undescended testicle (UDT) • Referral early – goal is orchidopexy by 1 yo • What is the most sensitive diagnostic tool for UDT? • Ultrasound • CT • MRI • Pediatric Urologist

50. 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