TO PEE OR NOT TO PEE THAT IS THE QUESTION URINE TROUBLE TO PEE OR NOT TO PEE THAT IS THE QUESTION Shawn McGlew PA-C, DFAAPA Kennebec County Urology Manchester/Oakland, ME

Pre-Test T or F Incontinence is natural part of aging for women not men. Renal ultrasound is the best imaging study for stones. A high sodium diet is the number one reason for stones. Finasteride is a first line treatment for BPH. If CT sees a stone no further imaging is needed. Renal U/S is the most cost effective for hematuria.

I can’t pee. I pee to much. It hurts. I’m peeing blood. Urology Made Easy I can’t pee. I pee to much. It hurts. I’m peeing blood.

Bladder Outlet Obstruction Prostate Strictures Poor pelvic floor relaxation Other pathology

Bladder Outlet Obstruction Incomplete bladder emptying Hesitancy Nocturia Urgency with or without leaking Frequency Pelvic pain

Bladder Outlet Obstruction Evaluation: U/A PE / DRE PSA PVR Cysto and/or UDS +\-

Bladder Outlet Obstruction TREATMENT: Conservative – voiding techniques Alpha Blockers 5 Alpha Reductase Inhibitors CIC Foley SP tube

Bladder Outlet Obstruction Alpha Blockers: Tamsulosin (Flomax) Terazosin (Hytrin) Doxazosin (Cardura) Silodosin (Rapaflo) Alfuzosin (Uroxatral)

Bladder Outlet Obstruction 5 Alpha Reductase Inhibitors: Blocks Testosterone conversion to DHT in the prostate. Not first line Consider PSA (getting it and correction) Side effects - breast tender/enlarge, low vol. ejaculate.

Bladder Outlet Obstruction Others: Combinations – Jalyn (Dutasteride / Tamsulosin Tadalafil (Cialis) low dose daily CIC Foley, SP Tube Surgery - TURP

CIC Clean Intermittent Catheterization Foley Cath SP Tube

I Gotta Peeee!!!

Urinary Urgency Incontinence Frequency

Urgency w/wo leaking History & physical – voiding history, foods, liquids, stress. PVR, U/A Treatment: AUA Guidelines Behavioral changes, Bladder training, Physical Therapy, Trial ACh medication Work-up if not improved – Cysto, UDS, CT +/- Other treatments: Beta 3 agonist, Neuromodulation, Botox

Urgency w/wo leaking Anticholinergics: Oxybutynin (Ditropan) Tolterodine (Detrol) Fesoterodine (Toviaz) Trospium (Sanctura) Solifenacin (Vesicare) Darifenacin (Enablex) Flavoxate (Urispas)

Urgency w/wo leaking Beta 3 Agonist: Mirabegron (Myrbetriq) – Relaxes bladder during filling

Urgency w/wo leaking Side Effects: Dizziness Dry mouth Constipation Urinary retention Contraindicated in narrow angle glaucoma

Leaking with cough, sneeze, laughing, getting up. Stress Incontinence Leaking with cough, sneeze, laughing, getting up.

Stress Urinary Incontinence Treatments: Behavior modification – timed voids, diet, fluids Absorbent pads Kegels Periurethral bulking therapy Surgery

Mixed Incontinence

Kidney Stones

Kidney stones Presentation: Classic, not so classic Composition: Ca, Ox, Phosphate, uric acid, struvite (magnesium ammonium phosphate) Prevalence: 1 in 8 will develop stone by age 70 and usually before 50 Think about stone with recurrent UTIs due to: Klebsiella, Proteus, Pseudomonas, Enterococcus. Work up: imaging > CT vs KUB vs RUS Treatment: Flomax, ESWL, Ureteroscopy, PNL, Prevention: 24 hour urines, hydration, low Na, low Ox, hydration.

Hydration, Hydration, Hydration…. Kidney Stones Hydration, Hydration, Hydration…. Urine SG > 1.010

Hematuria Gross: not disgusting… You can see it. Microscopic: more than 3 RBC /HPF Smokers: bladder cancer risk x5 Etiology: Stones, infection, kidney disease, prostate, neoplasm. Pathology: benign, malignant. Work up: 3 C’s Follow up for negative evaluation: U/A micro, cytology 3 years

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