2. 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

3. 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.

4. 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.

6. Bladder Outlet Obstruction
Prostate
Strictures
Poor pelvic floor relaxation
Other pathology

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

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

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

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

12. 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.

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

14. CIC
Clean Intermittent Catheterization
Foley Cath
SP Tube

16. I Gotta Peeee!!!

17. Urinary Urgency Incontinence Frequency

19. 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

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

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

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

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

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

25. Mixed Incontinence

28. Kidney Stones

30. 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.

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

37. 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

38. THE END