1. 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

2. My Contact Information
(Preferred!!)
Pager
(510)
Phone
(510)
PLEASE DO NOT GIVE THIS INFORMATION TO PATIENTS

3. Overview/Goals Urology Referrals Topics
How to approach the most common problems
Providing a useful workup when consulting
Improved collaboration
BPH & Urine Retention
Hematuria
Incontinence
Infections of the urinary tract
Elevated PSA
Stones
Provide a toolkit for temporizing most nonurgent, medically treated urologic problems and tips for streamlining the referral process

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
Many urological problems are actually nonsurgical and are able to be handled by primary care providers, with the right information.
Tonight is the start of empowering you with that information so that your patients don’t get lost in these statistics
With so many patients scheduled for each clinic, we often see our last patient after 7:30 pm in the evening. Bad for clinic staff, bad for me and the residents, especially bad for the patients.

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
My motto: To pee, see YOU because this is something that you can take care of yourselves as long as the patient doesn’t require surgery

6. LUTS Obstructive Irritative Weak stream Intermittency Hesitancy
Incomplete voiding
Postvoid dribbling
Straining to void
Valsalva
Frequency
Urgency
Nocturia
Dysuria
The irritative sx happen with progressive BOO because the bladder is overworked

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
I typically do cystoscopy on men younger than 50 right away if they present with long standing LUTS.
Often urethral stricture

9. The degree of outlet obstruction and prostatic size does not correlate with symptom score.

10. 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

11. 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

12. 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
Leg elevation mobilizes LE extremity fluid into the circulation and helps eliminate it before sleep.

13. Medications Alpha blockers 5-alpha reductase inhibitors
Works over days
Relaxes smooth muscle in urethra
5-alpha reductase inhibitors
Shrinks the prostate
Good for bleeding
Prevents/treats obstruction
PSA drops by 50%
Side effects: sexual, gynecomastica
Works over months

14. 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 blocker
Tamsulosin—Flomax (eff dose mg 30 min qAC)
*No need to titrate
I recommend tamsulosin for patients in urinary retention
Terazosin and Doxazosin are chronically underdosed

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

16. Urinary Retention Pre-existing partial obstruction (e.g. BPH)
Sudden increased outlet resistance or decreased detrusor pressure
Precipitating event:
Infection
Bleeding
Overdistention
Effective urination requires an open outlet and enough outward pressure generated by the bladder.. Problems occur when either of these things don’t work correctly.

17. Treatment
Gross hematuria (clot retention, bladder decompression bleeding), Renal failure, febrile UTI
Admission to hospital through ER
Most patients
Foley Catheter for 10 days
Start alpha blocker
Patients in complete retention
Start 5 alpha reductase inhibitor
10 days of bladder decompression needed to reset the detrusor muscle. Find out from patient or ER how much urine drained. If >500 mL then do not take catheter out too soon. Will fail voiding trial because of the bladder, not because of med not working.

18. Referral AUA SS What medications, doses and how long Cr PVR
Infections, urinary retention or gross hematuria

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

20. Hematuria Many benign causes, some malignant
We don’t want to miss cancer
Urgent:
Passing clots, can’t void
Blood loss anemia (rare)
Not urgent:
Able to void
Normal H/H, normal Cr

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

22. Workup—Gross Hematuria
When to send to ER
UA/Cx (nitrite positive?)
CBC
Chem7
CT urogram (3 phase scan with IV contrast)
Follow-up for cystoscopy
Dropping H/H
Unrelenting Clot retention

23. 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 OR
u/s or noncon might be helpful

24. 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!!

25. Filling Defects

26. Cystoscopy-tumors

27. 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
Involuntary loss of urine
Classification is based on the symptoms

28. Transient Urinary Incontinence “DIAPPERS”
Delirium
Infection
Atrophic vaginitis
Pharmaceuticals/polypharm
Psychological (esp. depression)
Excessive production (diuretics, DM)
Restricted Mobility (PD, arthritis)
Stool impaction/Constipation
Think about these first. A very large number of patients wait months for me to fix their constipation.
Fix the underlying problem

29. “Urologic Incontinence”
A true urologic incontinence will usually fit into one of these categories.
Try to treat urge incontinence with anticholinergic medications first (Ditropan 5 mg PO TID or Ditropan XL 10 mg daily)

30. 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

31. Evaluation/include on referral:
History
Precipitating factors
Severity: # pads per day, how wet
Obstructive/irritative sx
OB history
Previous GU conditions
Previous pelvic surgery
Neurologic disease
Fluid consumption
Medications
Precipitating factors: Coughing, sneezing, lifting, straining, changes in body position, EtOH, caffeine, constipation, immobility
Previous GU conditions: strictures, STDs, UTIs, etc
Pelvic surgery: abdominoperineal resection, incontinence surgery, hysterectomy, prolapse surgery, prostatectomy, urethral surgery
Neurologic disease: MS, stroke, Parkinson’s, lumbar disc disease. Ask about sx: weakness, numbness, visual changes
Medications: Especially diuretics

32. Physical exam Pelvic exam on women Rectal exam Lower extremities
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

33. Infections Frequent urinary tract infections Epididymitis Orchitis
Prostatitis

34. Frequent UTIs Men: Think BPH or chronic bacterial prostatitis
Young women: Think Constipation, sexual activity
Postmenopausal women: Think atrophic vaginitis or constipation or both
The bane of my practice
Post menopausal women with asymptomatic UTIs do not require treatment

35. 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

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

37. 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

38. 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

39. Prostatitis Most commonly: NONBACTERIAL Acute Bacterial Prostatitis
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

40. 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

41. Treatment Acute prostatitis Chronic 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

42. 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

43. Prostate Cancer Screening
20% of my referrals are for elevated PSA or prostatic nodules

44. 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

45. Prostate cancer--Epidemiology

46. Screening Recommendations (AUA, NCCN, ACS)
Annual PSA and DRE
In men with > 10 years life expectancy:
Start 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

47. Digital Rectal Exam Abnormal DRE Normal DRE (age matched)
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

48. 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

49. Serum PSA levels “Normal” based on age My criteria for prostate biopsy
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
There is really no normal PSA. Prostate cancer has been found in men with PSA less than 1.

50. Stones

51. Flank Pain Workup History: Labs: Exam Imaging Previous stones?
Diabetic?
Length/severity of sx?
Fevers?
Severe n/v?
Labs:
WBC
sCr
UA: nitrites?
Exam
Febrile?
Helped with narcotics/antiemetics?
Imaging
Hydro? (obstructive?)
2 kidneys?
What I will ask for over the phone

52. Urolithiasis Absolute reasons for admission/immediate tx:
Obstructed pyelonephritis
Increasing renal insufficiency (e.g. Solitary kidney, bilateral stones)
Unrelenting pain or nausea/vomiting

53. Imaging Quick, available, no radiation Not very sensitive for hydro
Gold standard: Noncontrast CT scan
Radiation, expensive, in-demand resource
Ultrasound?
Quick, available, no radiation
Not very sensitive for hydro
Miss small stones
Cannot be used to plan surgical treatment
KUB
Quick, inexpensive, lower radiation dose
Problems: radiolucent stones, stool/poor sensitivity

54. 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 + stone
May have few sx

55. The passable stone < 4mm: >90% 4-6 mm: 70-80% 6-8 mm: 50-60%
>10 mm: unlikely
Assuming 6 weeks, with Flomax