Five Common Urological Problems Seen in Primary

Transcription

Five Common Urological Problems Seen in Primary
Five Common Urological
Problems Seen in Primaryy
Care
Jack H. Mydlo
Mydlo,, MD, FACS
Professor and Chair,, Dept
p of
Urology, Temple University
School of Medicine
Five most common problems

Voiding
g Dysfunction:
y
BPH obstruction, stricture, stone,
UTI, cancer, DM, etc.

Elevated PSA: BPH,
BPH prostatitis,
prostatitis UTI,
UTI

Erectile dysfunction: age, DM, HTN, smoking,

Hematuria: stones, UTI, tumors

Flank pain: stone, pinched nerve, cyst, spasm, weight
Problem # 1 Voiding Dysfunction
BOO (bladder outlet obstruction)
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Urethral compression
p
Retained urine
Nocturia, frequency
N
Narrow
stream
Check fluid intake
Check for diabetes
Check for strictures
Check for CHF, etc.
Prostate CancerCancer-usually
asymptomatic
Hematuria
Treatment
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Rule out medical problems and strictures
Check post void residual by ultrasound
Fl id restriction
Fluid
i i after
f di
dinner, void
id qhs
h
Alpha blocker alone, esp,
esp, if gland < 40 gms
Alpha blocker and finasteride if > 40 gms
Baseline PSA level
Can add antianti-cholinergic for symptoms if nl
PVR
Case A
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67 year old male with increased nocturia
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T k Tamsulosin
Takes
T
l i qhs
h but
b minimal
i i l
improvement

DRE: 50 g
grams,, smooth,, benign,
g , PSA nl
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Drinks coffee and several sodas at night
Case A Evaluation and Plan
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Decrease fluid after dinner,
dinner void before
bedtime
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Sono to determine residual. Consider
adding
ddi Proscar
P
if gland
l d greater than
h 40
grams
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Make sure no hx of STD’s: stricture
formation
Case B

48 year old female with urgency and
frequency. Hx of smoking
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Failed ditropan 5 mg daily
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Also complained
p
of stress urinaryy
incontinence
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Drinks lot of tea and coffee
Case B Evaluation and Plan
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Make sure she is on enough ditropan
ditropan,, can
go up to 15 mg
Can switch to Detrol,
Detrol Vesicare
Vesicare,,
Limit caffeine intake
For SUI, consider ImipramineImipramine-has
anticholinergic effect on detrusor, and
alpha--adrenergic effect on bladder neck
alpha
Urine cytology,
y
gy, check for hematuria
Case C
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40 year old female presents cannot void
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N other
No
h physical
h i l complaints,
l i
no h
hematuria
i
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Non--smoker, non
Non
non--drinker
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Exercises daily
Case C Evaluation and Plan
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Check sono and post void residual to make
sure not dehydrated, R/O retention
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Hx of energy drinks or drugs? BN spasm
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Hx of stones or hematuria? Stone/clot
/
clog
g
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Neurological exam: rule out MS: AUR 1st
Problem # 2 Elevated PSA
Made by epithelial cells,
cells not stromal cells
 Can be elevated in BPH, CAP, prostatitis,
UTI ejaculation,
UTI,
ejaculation not DRE
 Free PSA not as important as total PSA and
PSA velocity
l i ((> 00.55 ng
ng/dl/
/dl/yr
/dl/yr
 DRE is as important as
PSA to screen for CAP
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Transrectal needle biopsy of
prostate (TRUS or finger guided)
Evaluation of Elevated PSA
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Repeat to be sure
May consider course of antibx for wk,
wk, then
repeat
Negative bx does not R/O cancer!!! If PSA
still
ill elevated,
l
d 2ndd bx
b detects
d
24% missed
i d CA
Finasteride can increase detection (but ½
PSA)
Not everyone
y
with prostate
p
cancer needs Rx
General rule for CAP: > 70: RT, < 70: Surg
Case A
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51 year old WM with PSA of 3.5, normal
DRE
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TRUS Bx of prostate negative for cancer
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Repeat PSA still elevated, what to do next?
Case A Evaluation and Plan
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Free PSA not helpful compared to total PSA
22--24% off prostate cancers are d
22
detected
d 2ndd
time
Can give course of antibx to lower
inflammation, r/o UTI, ejaculation, etc
Can start Proscar to shrink gland, increase
detection of CaP
Case B: 55 year old male with GS
6 CaP
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Sexually active
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Medically healthy otherwise
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Considers radiation vs surgery. What you
should know
Not the
Way to
Select
Treatment..
Surgery vs. Radiation
80%
70%
60%
50%
RRP
XRT
BTX
40%
30%
20%
10%
0%
5 yyr
10 yyr
> 10 yyr
External Beam Therapy/ 3D
Conformal Therapy
Prostate Brachytherapy
Hoffman et al, Am J Med 119:418,
2006
Surgery
Radiotherapy
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81% 10 yr. survival
Incontinence: < 5%
ED: 45%
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78% 10 yr survival
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Proctitis, cystitis: 15%
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ED: 4040-50%
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Fistulas: 22--3%
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Bladder Cancer: 0.6%
0 6%
Strictures: 8%
Complications of Radiation
Cystitis
Proctitis
Fistula Formation
Erectile Dysfunction
Bladder Cancer/Rectal Cancer
Robotic Surgery
RRP vs. RALP
Robotic Assisted Laparoscopic
Prostatectomy
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ED incidence not different than open RP
SUI iincidence
id
not diff
different than
h open RP
Less blood loss
Quicker discharge to home
For best results, check experience of
surgeon
Case A Evaluation and Plan
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Recommend surgery, discuss pros and cons
of open vs
vs. Robotic
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Discuss risks of ED, SUI
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Make sure partner is involved
Case B
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72 year old male with GS 7,
7 PSA 8
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H off MI
Hx
MI, on thinners,
hi
otherwise
h
i h
healthy
lh
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Not sexually active
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Life expectancy 15 years
Case B Evaluation and Plan
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Consider radiation: compare external beam
(daily for 15 minutes, 5 days/wk
days/wk for a month
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Brachytherapy, 1 ½ hours, OR, D/C in AM
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Risks of recurrence,, cystitis,
y
,p
proctitis
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Watchful waiting or consider surgery (> 15)
Problem # 3 Erectile
Dysfunction
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Hypertension: re
re--adjust BP meds
Diabetes
Smoking: #1 preventable cause
A
Age
Lipid profile
Psychological
Low libido: no testosterone if > 400 dl/ml
Erectile Dysfunction
Vascular Causes
Structural Changes
Atherosclerosis
Hypertension
Hypercholesterolemia
Functional Changes
Impairment of
endothelium-dependent
relaxations
Diabetes
Impairment
of neurogenic
relaxations
Arteries
Arterial
stenosis
Arterial insufficiency
Arteries
Impaired
p
vasodilation
Reduced inflow
Trabeculae
Smooth muscle
atrophy and
fibrosis
Excessive outflow
Corporo-venoocclusive disease
Trabeculae
Impaired
relaxation
Adapted from Tejada I et al. In: Erectile Dysfunction. Plymbridge Distributors; 2000:65
Reassurance for ED
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“Is
Is it too small?
small?” Self doubt is biggest
enemy of the penis. If you think small, you
are small.
small
Women complain if too big, not if too small
E
Every
male
l h
has llost erection
i
Every male has failed to satisfy a partner
Men take this in stride: happier, healthier
Avoid boredom: different positions, different
rooms, “anger/boredom can lead to ED”
Case A
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47 year old male with 6 month history of ED
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Ph i ll fi
Physically
fit, nonnon-smoking,
ki
married
i d 20 yrs
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Stress at work and home. Has morning
erections
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Good libido
libido, normal serum testosterone
Case A Evaluation and Plan
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Could try PDE5i
PDE5i, make sure he is educated
about the usage: empty stomach, no alcohol,
must be aroused,
aroused may need several attempts
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P h l i l IIntervention?
Psychological
i ? (AM erections)
i )
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If testosterone was low, can add hormone
supplement,
pp
, can salvage
g 35% of failures
Case B
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58 yo overweight male w 2 year hx of ED
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T ll you h
Tells
he h
has tried
i d all
ll three
h
PDE5i w
failure
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Hx of high
g blood pressure,
p
, diabetes &
smoking
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Happily married
Case B Evaluation and Plan
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Lose weight! Adipose tissue converts
testosterone to estrogen
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Stop smoking! #1 preventable/reversable
preventable/reversable
cause
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Re--educate about PDE5
Re
PDE5--i therapy: empty
stomach, up to 55-6 attempts, arousal
Case B Evaluation and Plan
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If meds still don
don’tt work,
work offer vacuum pump
combination
Offer MUSE (alprostadil
(alprostadil urethral
suppository
Off EDEX or Caverjet
Offer
C
j injection
i j i therapy
h
Case C
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52 year old WM on dialysis, on nitrates
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Still smokes cigarettes
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Getting married soon, wishes to correct ED
Case C Evaluation and Plan
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Case start self injection w EDEX or Caverjet
Can sometimes combine with PDE5i (but
not if on nitrates)
Can combine with vacuum therapy rehab
If fails, consider penile prosthesis
Problem # 4 Hematuria
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Causes: Stones, bladder cancer, BPH.
E l
Evaluate
smoking
ki hx
h , dyes,
hx,
d
other
h chemicals.
h i l
Make sure you have a “clean catch” urine
Send a urine cytology
Baseline renal/bladder sonogram
Needs urologic workup: CT, cysto,
cysto, cytology
Case A
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60 yo female had gross hematuria from
“UTI”
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It resolved when her UTI was treated with
antibiotics
ibi i
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Smoked 2 PPD for 40 years
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On blood thinners
Case A Evaluation and Plan
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Urine cytology
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CT off abdomen
bd
and
d pelvis
l i w/
/ and
d w/o
/
contrast
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Cystoscopy
y
py
Case A Results
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CT revealed
l db
benign
i renall cyst
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Cystoscopy revealed cystitis
Case B
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65 year old female with hx of smoking
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G
Gross
and
d microhematuria
i h
i
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On thinners
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No hx of trauma
Case B Evaluation and plan
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R exophytic lesion 5
cm
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Contralateral kidney
OK
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No major
j health issues
Case B Evaluation and Plan
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Watchful waiting for lesions < 3 cm
C
Cryoablation
bl i or RFA for
f older,
ld ffrail
il patients
i
Right nephrectomy possible, but overkill
Right partial nephrectomy best choice
Still needs cystoscopy to rule out other
pathology
Case C
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77 year old male with gross hematuria
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H off prostate cancer 10 years ago, had
Hx
h d XRT
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Symptoms of frequency, urgency, BOO
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Worked in oil refinery business
Case C Evaluation and Plan
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Urine cytology suspicious for malignancy
CT negative
i for
f llesions
i
iin kid
kidney and
d
bladder
PSA 2.2
Hx of HTN,, DM,, no MI or CVA
Case C Evaluation and Plan
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Refer to urologist
Cystoscopy reveals bladder tumor
Problem # 5 Flank pain
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Causes: stones,
stones UPJ obstruction,
obstruction renal
tumor, large renal cysts, aortic aneurysm
lumbar disc disease
Distinguish low back pain from flank pain
If hx
h off small
ll renall cyst, b
be wary: rarely
l the
h
cause of back pain
Sonogram, CT can be most helpful
Be waryy of drug
g seekers,, Munchausen’s,, etc
Renal Cysts: Bosniak Classification:
1
Complex Cysts: Bosniak
Classification 2, 3, 4
2: 10% malignancy
3: 20-40%
4: 90% malignancy
Ureteral stone
Ureteral stone
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Hydration Flomax if less than 6 mm,
Hydration,
mm or
recurrent

Lemonade (citric acid) prevents future
stones

If febrile: MUST GO TO ER FOR STENT
PLACEMENT or PERC,, and IV ATBX!
Renal Stone Treatments:
py, ESWL PCNL
Ureteroscopy,
Other causes of Flank Pain: UPJ
obstruction, AAA, Disc Disease
Case A
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46 year old female with complaints of
chronic flank pain
On PE, appears to be midline, no CVAT
No blood in urine
No fevers,, chills,, N or V
Sonogram negative for stone
Case A Evaluation and Plan

CT scan revealed herniated lumbar disc

Referred to neurosurgery for further
evaluation
Case B
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50 year old male referred for left flank pain

CT scan revealed
l d llarge lleft
f renall cyst 12 cm

CVAT lateralized to left

No major medical issues
Case B Evaluation and Plan

Interventional Radiology to aspirate cyst

If pain resolves, then cyst is cause of pain. If
no resolution, another cause for pain.

Consider surgical unroofing of cyst if cause
Case C
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50 year old nurse’s aid presents to office
Friday PM c/o flank pain
Imaging ((--) for stone, cyst or hydronephrosis
States she had fevers at home, now afebrile
States hx of hematuria,, but U/A
/ neg
g now
Initially very nice, but increasingly hostile
Reassurance



Classic Munchausen’s syndrome: medical
background history & symptoms “too
background,
classic”
D
Demands
d attention
i and
d more procedures
d
(i
(in
urology, sexual gratification from instrument
i
insertion)
i )
High rate of malpractice claims
Thank you

jmydlo@temple.edu
Questions
Question # 1

PSA can be elevated due to:

UTI
Prostatitis
Ejaculation
BPH
All of the above
N
None
off the
h above
b

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


Question # 1

PSA can be elevated due to:

All of the above
Question # 2

Erectile dysfunction
dysfunction, if found to be present
in a male with heavy smoking history

Can be improved or reversed upon cessation
off smoking
ki after
f 11--2 years
Will always need prosthesis since meds
won’t work
Is p
purelyy p
psychological
y
g
Has no good options



Question # 2

Erectile dysfunction
dysfunction, if found to be present
in a male with heavy smoking history

Can be improved or reversed upon cessation
off smoking
ki after
f 11--2 years
Question # 3

Localized prostate cancer
cancer, in general
general, can be
treated by:

Watchful waiting
External beam radiation or brachytherapy
Open
p surgery
g y or robotic surgery
g y
Treatment varies by age, health, desires of
patient
All of the above




Question # 3

Localized prostate cancer
cancer, in general
general, can be
treated by:

All of the above
Question # 4

Renal stones:

All must b
be treated
d surgically
i ll
Should not have trial of hydration if < 6 mm
Needs immediate stent or PCN if febrile
Never cause hematuria



Question # 4

Renal stones:

Needs immediate stent or PCN if febrile
Question # 5
Treatment of symptoms of BPH,
BPH including
nocturia,, include:
nocturia





Fluid restriction after dinner & voiding qhs
Evaluation of medical issues (DM, CKD)
Alpha
p blocker +/+/
/- finasteride
All of the above
None of the above
Question # 5
Treatment of symptoms of BPH,
BPH including
nocturia,, include:
nocturia

All of the above
Thank you

jmydlo@temple.edu

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