Presentation on theme: "Michael Jacobson MD PhD 2/12/12"— Presentation transcript:
1Michael Jacobson MD PhD 2/12/12 Basic Urology for Primary Care Providers Getting Yourself and Your Patients Beyond ”Please Hold”Michael Jacobson MD PhD2/12/12
2My Contact Information(Preferred!!)Pager(510)Phone(510)PLEASE DO NOT GIVE THIS INFORMATION TO PATIENTS
3Overview/Goals Urology Referrals Topics How to approach the most common problemsProviding a useful workup when consultingImproved collaborationBPH & Urine RetentionHematuriaIncontinenceInfections of the urinary tractElevated PSAStonesProvide a toolkit for temporizing most nonurgent, medically treated urologic problems and tips for streamlining the referral process
4Background The Long Wait Nonurgent urology consult 8-9 months Cancer 6-8 weeks consult+8-10 weeks surgeryObstructive stones6-8 weeks+12 weeks surgery65-80 patients scheduled each clinicMany 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 statisticsWith 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.
5Benign Prostatic Hypertrophy 50% men > 60 yo90% men > 80 yoNonmalignant, uncontrolled prostatic growthBladder Outlet ObstructionLower urinary tract sx (LUTS)ObstructiveIrritativeHematuriaMy 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
6LUTS Obstructive Irritative Weak stream Intermittency Hesitancy Incomplete voidingPostvoid dribblingStraining to voidValsalvaFrequencyUrgencyNocturiaDysuriaThe irritative sx happen with progressive BOO because the bladder is overworked
8Helpful tip: Men older than 60 who have LUTS USUALLY have BPHMen younger than 50 who have LUTSALMOST NEVER have BPHI typically do cystoscopy on men younger than 50 right away if they present with long standing LUTS.Often urethral stricture
9The degree of outlet obstruction and prostatic size does not correlate with symptom score.
10Initial Workup Digital Rectal Exam UA PSA (> 10 years life expectancy)Post void residual (Ultrasound or bladder scanner)Normal < 100 mLOver 100 mL: BPH should be treatedGoal of therapy: PVR < 100AUA symptom score
11Treatment options for BPH Surveillance with general measuresAUA SS < 8Yearly re-evaluation with “initial workup”MedicationsHerbalAlpha blockers5 alpha reductase inhibitorsSurgicalMinimally invasiveTURPSimple prostatectomy
12General Measures Avoid substances that make symptoms worse Alpha agonistsDecongestants with pseudoephedrineEphedraCaffeine and EtOHSpicy and acidic foodsReduce nocturia:Decrease fluids in the eveningAvoid diuretics in the eveningLE edema: elevate legs one hour before bedLeg elevation mobilizes LE extremity fluid into the circulation and helps eliminate it before sleep.
13Medications Alpha blockers 5-alpha reductase inhibitors Works over daysRelaxes smooth muscle in urethra5-alpha reductase inhibitorsShrinks the prostateGood for bleedingPrevents/treats obstructionPSA drops by 50%Side effects: sexual, gynecomasticaWorks over months
14Alpha 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 blockerTamsulosin—Flomax (eff dose mg 30 min qAC)*No need to titrateI recommend tamsulosin for patients in urinary retentionTerazosin and Doxazosin are chronically underdosed
16Urinary Retention Pre-existing partial obstruction (e.g. BPH) Sudden increased outlet resistance or decreased detrusor pressurePrecipitating event:InfectionBleedingOverdistentionEffective urination requires an open outlet and enough outward pressure generated by the bladder.. Problems occur when either of these things don’t work correctly.
17TreatmentGross hematuria (clot retention, bladder decompression bleeding), Renal failure, febrile UTIAdmission to hospital through ERMost patientsFoley Catheter for 10 daysStart alpha blockerPatients in complete retentionStart 5 alpha reductase inhibitor10 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.
18Referral AUA SS What medications, doses and how long Cr PVR Infections, urinary retention or gross hematuria
20Hematuria Many benign causes, some malignant We don’t want to miss cancerUrgent:Passing clots, can’t voidBlood loss anemia (rare)Not urgent:Able to voidNormal H/H, normal Cr
21Gross vs Microhematuria Pink LemonadeCool AidRed WineMotor OilKetchupMicrohematuria> 5 RBC per High Power FieldAt least 2 separate UasNeed microscopic, dipstick not enough!Not explained by infection
22Workup—Gross Hematuria When to send to ERUA/Cx (nitrite positive?)CBCChem7CT urogram (3 phase scan with IV contrast)Follow-up for cystoscopyDropping H/HUnrelenting Clot retention
23Microscopic hematuria workup Urine culture, UA with micro x 2, CBC, chem 7Upper tract imaging: CT IVP (with delayed phase)Referral for cystoscopy(last part of the workup)For patients with elevated creatinine, refer without CT scanretrograde pyelogram in the ORu/s or noncon might be helpful
24CT IVP (CT Urogram) 3 phases: Noncontrast Abdomen/Pelvis Shows stonesArterial PhaseShows vascular tumors (kidneys)Delayed phaseOpacifies urinary tractShows filling defects (possible tumors)CT IVP does not adequately evaluate the bladder!!
27Incontinence Stress urinary incontinence Increase in abdominal pressureCoughingSneezingStrainingLiftingBendingExercising/exertionUrge urinary incontinenceAccompanied by urgeMixed incontinenceBoth stress and urgeContinuous incontinencee.g. secondary to fistulaOverflow incontinenceAssociated with poor emptyingInvoluntary loss of urineClassification is based on the symptoms
28Transient Urinary Incontinence “DIAPPERS” DeliriumInfectionAtrophic vaginitisPharmaceuticals/polypharmPsychological (esp. depression)Excessive production (diuretics, DM)Restricted Mobility (PD, arthritis)Stool impaction/ConstipationThink 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)
30What you can try for urge incontinence first Anticholinergic medicationsDitropan 5 mg po TID or Ditropan XR 10 mg po dailyUrinary retentionDry mouth, dry eyes, constipationDeliriumVesicare, Detrol, etcFor post menopausal women with no history of breast or GYN cancer:Vaginal Premarin or Estrace creamPea size daily x 4 weeks then 2x per week
31Evaluation/include on referral: HistoryPrecipitating factorsSeverity: # pads per day, how wetObstructive/irritative sxOB historyPrevious GU conditionsPrevious pelvic surgeryNeurologic diseaseFluid consumptionMedicationsPrecipitating factors: Coughing, sneezing, lifting, straining, changes in body position, EtOH, caffeine, constipation, immobilityPrevious GU conditions: strictures, STDs, UTIs, etcPelvic surgery: abdominoperineal resection, incontinence surgery, hysterectomy, prolapse surgery, prostatectomy, urethral surgeryNeurologic disease: MS, stroke, Parkinson’s, lumbar disc disease. Ask about sx: weakness, numbness, visual changesMedications: Especially diuretics
32Physical exam Pelvic exam on women Rectal exam Lower extremities Check for atrophic vaginitisObvious prolapseCough testRectal examStool impaction, sphincter toneLower extremitiesEdema can cause excess urine production at nightNeurologicalPerineal sensation, anal sphincter toneBulbocavernosus reflex
34Frequent UTIs Men: Think BPH or chronic bacterial prostatitis Young women: Think Constipation, sexual activityPostmenopausal women: Think atrophic vaginitis or constipation or bothThe bane of my practicePost menopausal women with asymptomatic UTIs do not require treatment
35Relapsing UTI classification Bacterial persistence versus re-infectionBacterial persistence:Antibiotics eradicate bacteria from the urine temporarilyOften associated with foreign body or stoneUrine culture showing the same bacteria repeatedlyEvaluationUrine culture prior to each treatment with appropriate abxRenal/bladder u/s plus KUB (Stones? PVR? Hydro?)Check blood sugar
36Treatment Women with afebrile UTIs Men 3 days antibiotics Check urine culture before starting empiric treatmentMen10-14 days of abx
37Epididymo-Orchitis Presentation Testicular pain (Ddx: testicular torsion)Sudden onset of intense pain TorsionGradual onset epididymo-orchitisAssociated with STD: with urethritis and urethral dischargeMay be associated with UTISwelling/tenderness of testis, epididymis and/or cord+/- scrotal erythema or edema+/- fever+/- hydroceleALL PATIENTS REQUIRE A SCROTAL ULTRASOUND
38Epididymo-Orchitis--Treatment InfectiousMen < 35 years old:STD (Neisseria gonorrhoeae and Chlamydia trachomatis)Treat with Rocephin 250 mg IM single dose + Doxycycline 100 mg po BID x 10 daysCheck urine culture firstCheck urethral swab or GC urine test firstMen > 35 years old: most common E. coliInitial treatment: Levofloxacin x 10 daysAdjust according to urine culturePain/fever usually improve after 3 days. Induration may take weeks/monthsIf symptoms return then treat up to 6 weeks with antibiotics
39Prostatitis Most commonly: NONBACTERIAL Acute Bacterial Prostatitis Chronic prostate syndromes: PainGU pain, back pain, suprapubic pain, perineal pain, dysuria, frequency, urgency, painful ejaculationAcute Bacterial ProstatitisUsually diagnosed in YOUNG MENMost common: E.coliFever, irritative/obstructive voiding sx, extremely tender and warm/boggy prostate
40Prostatitis--continued Chronic Bacterial ProstatitisRecurrent, symptomatic infectionGU pain, back pain, suprapubic pain, perineal pain, dysuria, frequency/urgency, painful ejaculationUsually diagnosed in OLDER MENMost common organism: E.ColiAssociated with prostatic calculi (nidus)Most common cause of recurrent UTIs in adult males
41Treatment Acute prostatitis Chronic prostatitis Emergency room—especially if with high feverWill need 4-6 weeks of post hospitalization antibioticsIf not hospitalized, get urine culture and start a fluoroquinoloneConsider tylenol, stool softeners, analgesicsChronic prostatitis8-16 weeks of initial antibiotic therapyReculture if symptoms return or persistsRecurrent: 6 months suppressive abx
42Nonbacterial Prostatitis Treatment:Empiric 6-8 week course of TMP-SMX or fluoroquinoloneIf no response then doxycycline 100 mg po bid for 4-6 weeksIf no response then no further antibiotic treatmentConsideralpha blockadeStress reduction/meditationDiet improvementDiazepam (pelvic floor relaxation)Pelvic PT for pelvic floor relaxation)Pain specialist
43Prostate Cancer Screening 20% of my referrals are for elevated PSA or prostatic nodules
44Prostate Cancer Screening and Diagnosis PSA and DREIncrease in detectionStage shiftPrior to screening: CaP detected when caused local symptoms or metsNow: > 90% CaP detected when potentially curableAsymptomatic
46Screening Recommendations (AUA, NCCN, ACS) Annual PSA and DREIn men with > 10 years life expectancy:Start for high risk of CaPStart 50 other men>70 if healthy with >10 years life expectancyPrior to testing, discuss benefits and limitations of CaP detection and treatment
47Digital Rectal Exam Abnormal DRE Normal DRE (age matched) CaP diagnosis in 15%-25%Normal DRE (age matched)<5% cancer prevalenceNot accurate or sensitiveBut abn DRE with elevated PSA: 5x increased risk of CaP
48PSA—Prostate Specific Antigen Serum protease produced only in prostate epitheliumCauses semen to become less viscousIncrease in serum PSAProstate cancerProstatitis or UTIBPHUrinary retentionEjaculationCatheterization
49Serum PSA levels “Normal” based on age My criteria for prostate biopsy 40’s: less than 1 ng/dL50’s: less than 2.560’s: less than 4My criteria for prostate biopsy40’s: >1 and increasing by 0.3/year50’s: > 2.5 and/or increasing by 0.3/year60’s: > 4. If > 4 increasing by 0.7/year, if <4 increasing by 0.3/yearAny abnormal DREThere is really no normal PSA. Prostate cancer has been found in men with PSA less than 1.
51Flank Pain Workup History: Labs: Exam Imaging Previous stones? Diabetic?Length/severity of sx?Fevers?Severe n/v?Labs:WBCsCrUA: nitrites?ExamFebrile?Helped with narcotics/antiemetics?ImagingHydro? (obstructive?)2 kidneys?What I will ask for over the phone
52Urolithiasis Absolute reasons for admission/immediate tx: Obstructed pyelonephritisIncreasing renal insufficiency (e.g. Solitary kidney, bilateral stones)Unrelenting pain or nausea/vomiting
53Imaging Quick, available, no radiation Not very sensitive for hydro Gold standard: Noncontrast CT scanRadiation, expensive, in-demand resourceUltrasound?Quick, available, no radiationNot very sensitive for hydroMiss small stonesCannot be used to plan surgical treatmentKUBQuick, inexpensive, lower radiation doseProblems: radiolucent stones, stool/poor sensitivity
54Immediate referral for drainage SepsisFever with UTI (and stone) or elevated WBCCreatinine 0.5 higher than baselineSolitary kidney (or functionally solitary)(Uncontrollable pain or vomiting)Beware of the diabetic patient with UTI + stoneMay have few sx
55The passable stone < 4mm: >90% 4-6 mm: 70-80% 6-8 mm: 50-60% >10 mm: unlikelyAssuming 6 weeks, with Flomax