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Michael Jacobson MD PhD 2/12/12

Basic Urology for Primary Care Providers Getting Yourself and Your Patients Beyond ” Please Hold ”. Michael Jacobson MD PhD 2/12/12. My Contact Information. Email (Preferred!!) mjacobson@acmedctr.org Pager (510) 231-3157 Phone (510) 798-4537. Overview/Goals. Urology Referrals.

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Michael Jacobson MD PhD 2/12/12

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  1. Basic Urology for Primary Care ProvidersGetting Yourself and Your Patients Beyond ”PleaseHold” Michael Jacobson MD PhD 2/12/12

  2. My Contact Information • Email (Preferred!!) • mjacobson@acmedctr.org • Pager • (510) 231-3157 • Phone • (510) 798-4537

  3. Overview/Goals UrologyReferrals Topics BPH & Urine Retention Hematuria Incontinence Infections of the urinarytract Elevated PSA Stones • How to approach the mostcommon problems • Providing a usefulworkupwhenconsulting • Improvedcollaboration

  4. Background The 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

  5. 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

  6. LUTS Obstructive Irritative Frequency Urgency Nocturia Dysuria • Weak stream • Intermittency • Hesitancy • Incomplete voiding • Postvoid dribbling • Straining to void • Valsalva

  7. LUTS Differential Diagnosis • BPH • UTI • Primary bladder dysfunction (MS, neurogenic bladder, DM) • Prostatitis/chronic pelvic pain • Urethral stricture • Stones • Prostate cancer, Bladder cancer

  8. Helpful tip: • Men older than 60 who have LUTS • USUALLY have BPH • Men younger than 50 who have LUTS • ALMOST NEVER have BPH

  9. Initial Workup • Digital Rectal Exam • UA • PSA (> 10 years life expectancy) • 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

  10. 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

  11. General Measures • Avoid substances that make symptoms worse • Alpha agonists • Decongestants with pseudoephedrine • Ephedra • Caffeine and EtOH • Spicy and acidic foods • Reduce nocturia: • Decrease fluids in the evening • Avoid diuretics in the evening • LE edema: elevate legs one hour before bed

  12. Medications • Alphablockers • Works over days • Relaxessmoothmuscle in urethra • 5-alpha reductase inhibitors • Shrinks the prostate • Good for bleeding • Prevents/treatsobstruction • PSA drops by 50% • Sideeffects: sexual, gynecomastica • Works over months

  13. Alpha Blockade • Alpha-1 blockers (posturalhypotension): • Terazosin (effdose: 10 mg qhs) • Doxazosin (effdose: 8 mg qhs) *Always titrate alpha-1 blockers to avoidhypotension/syncope. • Alpha 1-a blocker • Tamsulosin—Flomax (effdose 0.4-0.8 mg 30 min qAC) *No need to titrate I recommendtamsulosin for patients in urinary retention

  14. Surgical Therapy • Strong indications • Refractory urinary retention • Recurrent UTIs • Refractory gross hematuria • Bladder stones • Renal insufficiency • Moderate indications • AUA SS > 8 and • Substantial bother • Increasing PVR

  15. Urinary Retention Pre-existingpartialobstruction (e.g. BPH) Sudden increased outlet resistance or decreaseddetrusor pressure Precipitating event: Infection Bleeding Overdistention

  16. Treatment • Gross hematuria (clot retention, bladder decompression bleeding), Renalfailure, febrile UTI • Admission to hospital through ER • Most patients • FoleyCatheter for 10 days • Start alphablocker • Patients in complete retention • Start 5 alphareductase inhibitor

  17. Referral • AUA SS • Whatmedications, doses and howlong • Cr • PVR • Infections, urinary retention or gross hematuria

  18. Hematuria Differential Diagnosis Cancer (painless) Bladder, Kidney, Prostate Infection Stones BPH Trauma Medications/toxins Benign/idiopathic

  19. Hematuria • Many benign causes, somemalignant • Wedon’twant to miss cancer • Urgent: • Passingclots, can’tvoid • Blood loss anemia (rare) • Not urgent: • Able to void • Normal H/H, normal Cr

  20. Gross vs Microhematuria • Gross • Pink Lemonade • Cool Aid • Red Wine • Motor Oil • Ketchup • Microhematuria • > 5 RBC per High Power Field • At least 2 separate Uas • Needmicroscopic, dipstick not enough! • Not explained by infection

  21. Workup—Gross Hematuria Workup When to send to ER Dropping H/H UnrelentingClot retention • UA/Cx (nitrite positive?) • CBC • Chem7 • CT urogram (3 phasescan with IV contrast) • Follow-up for cystoscopy

  22. Microscopichematuriaworkup • Urineculture, UA with micro x 2, CBC, chem 7 • Uppertractimaging: CT IVP (with delayedphase) • Referral for cystoscopy • (last part of the workup) • For patients with elevatedcreatinine, referwithout CT scan • retrograde pyelogram in the OR • u/s or nonconmight be helpful

  23. CT IVP (CT Urogram) • 3 phases: • Noncontrast Abdomen/Pelvis • Shows stones • Arterial Phase • Shows vascular tumors (kidneys) • Delayed phase • Opacifies urinary tract • Shows filling defects (possible tumors) • CT IVP does not adequately evaluate the bladder!!

  24. FillingDefects

  25. Cystoscopy-tumors

  26. Incontinence • Stress urinary incontinence • Increase in abdominal pressure • Coughing • Sneezing • Straining • Lifting • Bending • Exercising/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

  27. Transient Urinary Incontinence“DIAPPERS” • Delirium • Infection • Atrophic vaginitis • Pharmaceuticals/polypharm • Psychological (esp. depression) • Excessive production (diuretics, DM) • Restricted Mobility (PD, arthritis) • Stool impaction/Constipation

  28. “Urologic Incontinence”

  29. What you can try for urge incontinence first • Anticholinergic 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

  30. Evaluation/include on referral: • History • Precipitating factors • Severity: # pads per day, how wet • Obstructive/irritativesx • OB history • Previous GU conditions • Previous pelvic surgery • Neurologic disease • Fluid consumption • Medications

  31. 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

  32. Infections • Frequent urinary tract infections • Epididymitis • Orchitis • Prostatitis

  33. Frequent UTIs • Men: Think BPH or chronic bacterial prostatitis • Young women: Think Constipation, sexual activity • Postmenopausal women: Think atrophic vaginitis or constipation or both

  34. Relapsing UTI classification • Bacterial persistence versus re-infection • Bacterial persistence: • Antibiotics eradicate bacteria from the urine temporarily • Often associated with foreign body or stone • Urine culture showing the same bacteria repeatedly • Evaluation • Urine culture prior to each treatment with appropriate abx • Renal/bladder u/s plus KUB (Stones? PVR? Hydro?) • Check blood sugar

  35. Treatment • Women with afebrile UTIs • 3 days antibiotics • Check urine culture before starting empiric treatment • Men • 10-14 days of abx • Check urine culture before starting empiric treatment

  36. Epididymo-Orchitis • Presentation • 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 UTI • Swelling/tenderness of testis, epididymis and/or cord • +/- scrotal erythema or edema • +/- fever • +/- hydrocele • ALL PATIENTS REQUIRE A SCROTAL ULTRASOUND

  37. Epididymo-Orchitis--Treatment • Infectious • Men < 35 years old: • STD (Neisseriagonorrhoeae 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

  38. Prostatitis • Most commonly: NONBACTERIAL • Chronic prostate syndromes: Pain • GU pain, back pain, suprapubic pain, perineal pain, dysuria, frequency, urgency, painful ejaculation • Acute Bacterial Prostatitis • Usually diagnosed in YOUNG MEN • Most common: E.coli • Fever, irritative/obstructive voiding sx, extremely tender and warm/boggy prostate

  39. Prostatitis--continued • Chronic 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.Coli • Associated with prostatic calculi (nidus) • Most common cause of recurrent UTIs in adult males

  40. Treatment • Acute prostatitis • Emergency room—especially if with high fever • Will need 4-6 weeks of post hospitalization antibiotics • If not hospitalized, get urine culture and start a fluoroquinolone • Consider tylenol, stool softeners, analgesics • Chronic prostatitis • 8-16 weeks of initial antibiotic therapy • Reculture if symptoms return or persists • Recurrent: 6 months suppressive abx

  41. 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 treatment • Consider • alpha blockade • Stress reduction/meditation • Diet improvement • Diazepam (pelvic floor relaxation) • Pelvic PT for pelvic floor relaxation) • Pain specialist

  42. Prostate Cancer Screening

  43. Prostate Cancer Screening and Diagnosis • PSA and DRE • Increase in detection • Stage shift • Prior to screening: CaP detected when caused local symptoms or mets • Now: > 90% CaP detected when potentially curable • Asymptomatic

  44. Prostate cancer--Epidemiology

  45. Screening Recommendations (AUA, NCCN, ACS) • Annual PSA and DRE • In men with > 10 years life expectancy: • Start 40-45 for high risk of CaP • Start 50 other men • >70 if healthy with >10 years life expectancy • Prior to testing, discuss benefits and limitations of CaP detection and treatment

  46. Digital Rectal Exam Abnormal 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

  47. 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

  48. Serum PSA levels • “Normal” based on age • 40’s: less than 1 ng/dL • 50’s: less than 2.5 • 60’s: less than 4 • My criteria for prostate biopsy • 40’s: >1 and increasing by 0.3/year • 50’s: > 2.5 and/or increasing by 0.3/year • 60’s: > 4. If > 4 increasing by 0.7/year, if <4 increasing by 0.3/year • Any abnormal DRE

  49. Stones

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