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 PLEASE DO NOT GIVE THIS INFORMATION TO PATIENTS

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

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.

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

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

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

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

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

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

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

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.

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

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 0.4-0.8 mg 30 min qAC) *No need to titrate I recommend tamsulosin for patients in urinary retention Terazosin and Doxazosin are chronically underdosed

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

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.

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.

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

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

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

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

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

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

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!!

Filling Defects

Cystoscopy-tumors

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

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

“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)

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

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

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

Infections Frequent urinary tract infections Epididymitis Orchitis Prostatitis

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

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

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

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

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

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

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

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

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

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

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

Prostate cancer--Epidemiology

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

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

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

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.

Stones

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

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

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

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

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