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Office Urology

8/26/2012. 2. Introduction. Urological complaints are a common part of clinical practice this discussion seeks to elucidate these readily distinguishable and treatable complaints.What are they?. 8/26/2012. 3. Topics of Discussion. Hematuria Proteinuria FrequencyDysuriaIncontinence. 8/26/2012. 4

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Office Urology

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    1. 8/27/2012 1 Office Urology David Dayya, D.O., M.P.H. St. Barnabas Hospital

    2. 8/27/2012 2 Introduction Urological complaints are a common part of clinical practice this discussion seeks to elucidate these readily distinguishable and treatable complaints. What are they?

    3. 8/27/2012 3 Topics of Discussion Hematuria Proteinuria Frequency Dysuria Incontinence

    4. 8/27/2012 4 Hematuria Gross or microscopic? What are the associated symptoms if any? ( dysuria, frequency, urgency, foul malodorous urine, abdominal pain, incontinence, dysuria, incomplete voiding,Chemical irritants, urethral or vaginal discharge, pruritis) Is the hematuria real? (pseudohematuria) Office microscopic urine analysis?

    5. 8/27/2012 5 Pseudohematuria DDX Food dyes, beets Rifampin Pyridium Urates Myoglobinuria Hemoglobinuria Menses

    6. 8/27/2012 6 Hematuria DDX Infectious (Pyelonephritis, cystitis, urethritis, prostatitis, septic emboli) Acute febrile illness Nephrolithisasis (pelvic, ureteral, bladder) Glomerulonephritis ( PSGN, Membranoproliferative, SLE, Crescenteric, Goodpastures, Rheumatoid, Wegeners Glomerulomatosis) Neoplasms ( Bladder, Renal, lymphoma, leukemia, PCKD) Trauma Coagulopathy Malignant hypertension or hypotension Vascular ( RAS, Renal vein thrombosis, Thromboembolic, Sickle cell trait or disease) Interstitial nephritis Analgesic nephropathy, CTX, anticoagulants, Exercise

    7. 8/27/2012 7 Hematuria DDX Nonurinary tract causes Neoplasms of adjacent organs PID, Diverticulitis, Appendicitis, Endometritis, Peritonitis IBD

    8. 8/27/2012 8 Proteinuria Quantity? Association with frequency or polyuria, dysuria, frequency, urgency, etc.?

    9. 8/27/2012 9 Benign Proteinuria Fever Exercise Orthostasis Contrast dye

    10. 8/27/2012 10 Non Nephrotic range proteinuria Pyelonephritis TB Interstitial Nephritis ATN Nephrolithiasis Malignant Hypertension Urinary Tract neoplasms PCKD Trauma Hereditary nephritis Glomerular Nephritis

    11. 8/27/2012 11 Nephrotic range proteinuria Minimal Change disease Glomerulonephritis Glomerulosclerosis D.M. Amyloidosis Neoplasms ( Mets, myeloma, leukemia, lymphoma) Sarcoidosis Thyroid diseases (graves,myxedema) Sickle cell disease

    12. 8/27/2012 12 Nephrotic range proteinuria Toxins,drugs, vaccines Allergens Systemic or other serious infections CHF Valvular/Structural disease causing right sided congestion Preeclampsia Morbid Obesity Renal vein/Vena cava thrombosis Alports syndrome

    13. 8/27/2012 13 Dysuria UTI STD (Urethritis) Vulvovaginitis/Atrophic vaginitis Prostatitis Mechanical/Chemical irritation Allergic reaction Bladder outflow obstruction Tumor Sexual Abuse

    14. 8/27/2012 14 Laboratory Evaluation UA (repeat), UC&S Office Urine Microscopy 24 hour Urine collection Post void urinary catheterization CBC Bun/Cr CPK Albumin, Total Protein, LDH, Bilirubin (D/I) PSA/PAP Urine eosinophils ANA, ESR, RF, C3, C4, CH50

    15. 8/27/2012 15 Special Testing Renal Ultrasound Renal Scan IVU, Voiding cystourethrogram CT Angiography Cystoscopy Biopsy

    16. 8/27/2012 16 Incontinence Involuntary loss of urine so severe as to have social and hygienic consequences 30% of the elder;y 50% of N.H. patients Stigma

    17. 8/27/2012 17 Incontinence H&P including endocrinology, neurological, malignancy, surgery, parity, meds, pattern of voiding, bowel habits, sexual function, menopausal, voiding record, Neurological exam, mini mental status exam, abdominal exam, valsalva maneuver, rectal exam

    18. 8/27/2012 18 Incontinence Stress Incontinence Urge Incontinence Overflow incontinence Functional Incontinence

    19. 8/27/2012 19 Stress incontinence Urine loss during activities that increase intra-abdominal pressure caused when intravescicular pressure exceeds urethral sphincter pressure Kegel exercises, alpha agonists to increase smooth muscle tone at bladder outlet, Tricyclic antidepressants decrease detrusor activity contractility and increase outlet resistance, estrogen improves bladder tone Surgery for women with pelvic prolapse including bladder neck suspension and urethral sling procedures.

    20. 8/27/2012 20 Urge Incontinence Detrusor muscle irritability resulting in sudden urge that exceeds ability of urethral sphincter to maintain control resulting in leakage of urine. Chronic cystitis, infiltrative diseases, CNS lesions Bladder training, direct acting smooth muscle relaxants, anticholinergics, calcium antagonists, ERT

    21. 8/27/2012 21 Overflow incontinence The bladder is unable to empty normally resulting in the bladder becoming over distended and resulting in urine loss. Most common bladder outlet obstruction, BPH Crede maneuver or valsalva, alpha blockers to reduce sphincter tone, cholinergic agents to improve detrusor contractility Finasteride TURP,TUIP, TULIP

    22. 8/27/2012 22 Functional incontinence Non-urinary tract causes of incontinence

    23. 8/27/2012 23 DRIP Reversible incontinence Delirium, Dementia, Depression Restricted Mobility, Retention Infection, inflammation (atrophic vaginitis), impaction Pharmaceuticals, Polyuria (glucosuria, CHF)

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