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Urology primer -

Urology Primer

TOPICPage

  1. Quick Referral Guide: Indications for Urology Referrals2
  2. Bladder Outlet Obstruction/Prostatism 4
  3. Hematuria 6
  4. Erectile Dysfunction 7
  5. Urinary Incontinence 8
  6. Prostate Cancer 9
  7. Prostatitis12
  8. Renal Calculi13
  9. Urinary Tract Infection14
  10. Scrotal Masses15
  11. Circumcision16
  12. Testicular Torsion17
  13. Orchalgia18
  14. Appendix: AUA Scoring System19

1. Indications for Referral to Urology

1. Bladder Outlet Obstruction

  1. Moderate to severe obstructive and/or irritative symptoms that interfere with the quality of life. Are the symptoms severe enough that the patient would want to take chronic medications or consider surgery on the prostate to relieve the symptoms? Is the AUA Symptom Score greater than 15?
  2. Moderate to severe symptoms with post-void residual (PVR) 25% of bladder capacity or greater than 100cc – noted on imaging studies, when available.
  3. Prostatism associated with a urinary tract infection
  4. Hydronephrosis
  5. Bladder calculi
  6. Obstructive symptoms associated with urinary incontinence
  7. Hematuria (see topic 2)

2. Hematuria

Urological consultation should be obtained for a patient with hematuria once a UTI has been excluded or if the hematuria persists after as UTI has been appropriately treated.

3. Erectile Dysfunction

This condition can be treated initially by the PCP and a referral to Urology clinic is not necessary. Please do not refer Erectile Dysfunction to Urology at ACMC.

4. Urinary Incontinence

Overflow incontinence should be referred to urology. Stress and Urge incontinence should be managed in primary care. For women, the Gynecology service may be helpful.

5. Prostate Cancer Screening

  1. Abnormal prostate exam in a male less than 75 years of age
  2. PSA >10 in a male under the age of 75

6.Prostatitis

Refer treatment failures to Urology.

7. Renal Calculi

  1. Recurrent calculi
  2. Obstructing/symptomatic stone that has not passed in 2-3 weeks
  3. Residual renal calculi or staghorn calculi
  4. Obstructing stone > 4mm in diameter
  5. Recurrent UTI
  6. History of renal anomaly (solitary kidney, duplicated ureter, horsehoe kidney) or prior urological surgery.

8. Urinary Tract Infections

  1. History of urinary calculi
  2. Persistent hematuria (gross or microscopic) when uninfected
  3. Bacteria persistence in spite of adequate antibiotic therapy
  4. UTI symptoms in spite of negative cultures, and no other obvious cause

9. Scrotal Masses

If uncertain about your clinical diagnosis, get a scrotal ultrasound. Refer solid masses to Urology.

10. Circumcision

Adult Circumcision will not be preformed unless medically necessary (e.g. phimosis or recurrent balanitis)

11. Testicular Torsion

Every torsion should be referred as a Urological Emergency, that is, send to an Emergency Department and call a Urologist.

2. Bladder Outlet Obstruction (BOO)

Symptoms:

  1. Frequency: (normally every 3-5 hours) may increase due to detrusor irritability or incomplete bladder emptying or both.
  2. Nocturia: (awakening at night to urinate, normally once or twice during a night). Same etiology as for urinary frequency.
  3. Nycturia: The passage of increased volumes of urine during the night resulting from the mobilization of dependent edema or from the use of diuretics.
  4. Hesitancy: The interval of time before the urinary stream begins.
  5. Intermittent Stream: Stopping and starting the urinary stream.
  6. Difficulty stopping micturation/Terminal (post-void) dribbling
  7. Decreased force (and caliber) or urinary stream
  8. Feeling of incomplete bladder emptying
  9. Urgency and urge incontinence
  10. Overflow incontinence

Quantifying the symptoms: see AUA Symptom Score

Differential Diagnosis:

  1. Benign prostatic hyperplasia-BPH/Prostatism
  2. Prostate cancer-see discussion in this Primer (topic 5)
  3. Urethreal obstruction-history of prior instrumentation, catheterization, trauma or STD
  4. Inflammatory/Infectious conditions-cystitis, TB, prior pelvic radiation, bladder cancer
  5. Impaired detrusor contractility- history of neurological disease, prescribed and OTC Rx most commonly the anti-histamines, decongestants, tricyclic antidepressants, ETOH).
  6. Prostatitis/Prostatodynia-see discussion in this Primer (topic 6)

Physical Examination:

  1. Peripheral edema and signs of renal failure
  2. Abdomen-distended bladder, sense of urgency during suprapubic palpation
  3. Digital rectal examination (DRE)

Estimating prostate size Normal20 gmchestnut

1+25 gmplum

2+ 30-40 gmlemon

3+50-70 gmorange

4+70+ gmsmall grapefruit

TextureNormal: Feels like the thenar eminence

Abnormal (nodule): Feels like a knuckle

Natural history of bladder neck obstruction secondary to BPH:

30-60%-spontaneous symptomatic improvement

20-50%-subjective worsening of symptoms

05-20%-risk of developing acute urinary retention

Indications for Urological referral:

  1. Moderate to severe obstructive and/or irratative symptoms that interfere with the quality of life. Are the symptoms severe enough that the patient would want to take chronic medications or consider surgery on the prostate to relieve the symptoms? Is the AUA Symptom Score greater than 15?
  2. Moderate to severe symptoms with post-void residual (PVR) 25% of bladder capacity or greater than 100cc – noted on imaging studies, when available.
  3. Prostatism associated with a urinary tract infection
  4. Hydronephrosis due to BPH
  5. Bladder calculi
  6. Obstructive symptoms associated with urinary incontinence
  7. Hematuria (see topic 3)

Try alpha antagonists (Terazosin, Flomax, Cardura) prior to Urological consultation:

Start with:

Hytrin 1 mg qhs then after 3 days increase to 2 mg qhs

Cardura 2 mg qhs then after 3 days increase to 4 g qhs

Flomax 0.4 mg qam

Obtain the following prior to Urological consultation:

  1. UA/UC (per protocol)
  2. Serum creatinine
  3. AUA Symptoms Score

3. Hematuria

Definition: Blood in the urine

Types of Hematuria:

  • Microscopic (microhematuria – MH) - >5 RBC’ss per hpf,
  • Gross Hematuria (GH) – blood you can see (tea to red colored)
  • Heme + by dipstick is not enough. Obtain a microscopic analysis for RBCs

Etiology:

StonesTrauma/SportsTumors of GU tract

InfectionInflammationRenal (interstitial) disease

MedicationsHematologic diseaseIdiopathic

Background:

  • Microscopic hematuria is common (seen in approximately 15% of the general Population.
  • Hematuria can be intermittent even if associated with significant urological disease.
  • Smoking has an extremely strong association with bladder (transitional cell) cancer.
  • Significant urological lesions (those needing treatment) are found in 5-10% of patients with microscopic hematuria and in 15-20% of patients with gross hematuria.
  • Urological consultation should be obtained for a patient with hematuria once a UTI has been excluded or if the hematuria persists after as UTI has been appropriately treated.

Obtain the following prior to Urological consultation:

  1. At least 2 consecutive UA/Microscopic analysis performed 2 weeks apart in a lab to assess for microscopic hematuria. Dipstick UA is not sufficient.
  2. Serum Creatinine
  3. Imaging of the upper urinary tract: Contrast CT
  4. Renal ultrasound and KUB if allergic to contrast or increased creatinine.
  5. Please inform the patient that cystoscopy may be performed at the time of the Urological consultation.

4. Impotence / Erectile Dysfunction

This condition can be treated initially by the PCP and a referral to Urology clinic is not necessary.

Definition: The inability to attain and/or sustain an erection adequate for sexual intercourse.

TYPES

Psychogenic impotence:

  • Related to anxiety and/or stress preventing normal sexual function.
  • A clue to this diagnosis is history of normal nocturnal or morning erections.
  • Psychogenic impotence is likely in the absence of underlying medical conditions or drugs which can affect erections.
  • Prior to trying empiric therapy, it is reasonable to try one of the following:
  • a book titled,Male Sexuality, by Bernie Zibergeld
  • Mental health referral

Organic Impotence:

  • May be subdivided into endocrine, vasculogenic, neurogenic, or drug related.
  • Evaluation included urologic specific history and physical exam.
  • A serum testosterone is indicated in only those who complain of decreased libido or who have bilateral or atrophic testicles. If serum testosterone is low, a pooled serum testosterone (PST) should be obtained. If PST is low, then consider Endocrinology consultation. Use of testosterone therapy can cause accelerated progression of both benign and neoplastic growth of the prostate. If it is used, a patient must be made aware of these risks.

Treatment:

  • Continue to treat underlying conditions such as diabetes, tobacco use and hypertension.
  • Treatment is mainly empiric. We recommend Viagra with a starting dose of 50 mg taken an hour prior to intercourse. Patients must not be taking nitrates or alpha blockers. Patients also need to be told to review potential side effects with their pharmacist and that it is not a covered medication.
  • The vacuum erection device costs approximately $160. The vacuum erection device is effective in treating ALL types of impotency and produces satisfactory erections in 80% of men. Problems with the device can be referred directly to the supplier’s 1-800 phone number. Other treatments are available to patients include MUSE (prostaglandin urethral suppositories), intracavernosal injection of prostaglandin and implants (surgery).

Suggested treatment protocol for impotence:

  1. Rule out/treat diabetes
  2. Encourage cessation of smoking and reducing alcohol consumption
  3. Optimize anti-hypertension medications
  4. Offer vacuum erection or phosphodiesterase inhibitor
  5. Patients with premature ejaculation or anorgasmia should be treated by PCP.

5. Urinary Incontinence

Definition: Involuntary loss of urine

Classification:

  • Stress Urinary Incontinence (SUI): Incontinence associated with abdominal/pelvic stress, straining, or valsalva due to the loss of urethral and bladder support. SUI occurs most frequently in postmenopausal, multiparous women.
  • Urge Incontinence: Incontinence due to the bladder contracting without the patients intention to void. It is commonly associated with neurological diseases such as multiple sclerosis, Parkinson’s disease, spinal cord injury, myelodysplasia, stroke, cerebral palsy, and CNS tumor, but most frequently occurs due to overactive bladder without an apparent cause. In men, the most common cause is bladder outlet obstruction. Urge incontinence can occur at any age and is often a self-limiting process in those patients with an obvious cause.
  • Mixed Incontinence: Many women have both stress and urge incontinence. Usually one form of incontinence predominates in terms of causing the most distress and will dictate what form of treatment will be selected.
  • Overflow Incontinence: Occurs when a patient’s bladder no longer contracts so urine simply “pours over the top of the dam”. It can occur secondary to other medical conditions such as diabetes, spinal cord injury and myelodysplasia but is very often acquired through infrequent/inadequate voiding leading to bladder decompensation. It can also be precipitated by medications with anticholinergic properties (antihistamines, tricyclic antidepressants, etc…)

Treatment:

Stress incontinence:

  1. Kegel’s exercises to strengthen the pubococcygeus muscle.
  2. Alpha agonists like Sudafed.
  3. Referral for surgery if nonsurgical measures fail.

Urge incontinence:

Treatment is pharmacological with antimuscarinic agents like Ditropan, Detrol etc

Overflow incontinence should be referred to urology.

6. Prostate Cancer Screening

Recommendation:

“Rather than screening all men for prostate cancer as a matter of routine, physicians should describe the potential benefits and known harms of screening, diagnosis, and treatment; listen to the patient's concerns; and then individualize the decision to screen.”(AmericanCollege of Physicians)

Recommendations for specific modes of screening:

For men over age 75, there is no need for routine prostate evaluation in absence of significant symptoms.

  1. Digital Rectal Exam (DRE): A digital rectal examination can be used to assess the prostate gland in male patients over the age of 50.
  2. There is no need for routine prostate evaluation in asymptomatic men over age 75.
  3. For men below age 75 with abnormal prostate exams (nodules, induration, or asymmetry), refer to Urology.
  4. PSA:If after individualized risk/benefit discussion, the patient and physician decide PSA is appropriate,the following guidelines should be followed
  5. There is no role for obtaining a free PSA in primary screening. The free PSA is helpful for patients who have had a negative biopsy, with a PSAin 4-10 range, to determine whether another biopsy would be appropriate.
  6. No PSA testing should occur within:
  7. 48 hrs of digital prostate exam,
  8. 8 weeks after treatment of an episode of acute prostatitis or cystoscopy, etc.
  9. Men with mild-moderate obstructive symptoms and no mass or asymmetry, refer to 2a.
  10. For a normal exam and PSA results between 4-10, recheck after 8 weeks, before sending for consult. If the second recheck is below 4, do not refer. Recheck PSA in 12 months
  11. For men with obstructive symptoms and moderately enlarged prostate, but no palpable mass, and PSA between 4-10, see 2a.
  12. For a single result above 10 for men under the age of 75, referral to Urology is appropriate.

Discussion and Data for Use of PSA

Other causes of elevated PSA:

  1. Benign prostatic hyperplasia
  2. Acute prostatitis (wait 8 weeks after treatment to draw PSA)
  3. Prostate biopsy
  4. Cystoscopy
  5. TURP
  6. Urinary retention
  7. Ejaculation
  8. Digital rectal examination
  9. Perineal trauma
  10. Prostatic infarction
  • PSA measurements have considerable short-term variability
  • Roughly 70% of patients with an elevated PSA level between 4 and 10 will have a negative prostate biopsy. (source: American Urological Association)

“The use of PSA testing for the early detection of prostate cancer remains controversial, owing to its biological variability, high prevalence, and the strong evidence for over diagnosis and over treatment.” ( Prostate Specific Antigen Best Practice Statement: 2009 Update, American Urological Association)

“ Major scientific or medical organizations, including the American Cancer Society (ACS), US Preventive Services Task Force (USPSTF), American College of Physicians (ACP), National Cancer Institute (NCI), American Academy of Family Physicians (AAFP), and American College of Preventive Medicine (ACPM) do not support routine testing for prostate cancer at this time.

These organizations (the ACS, AUA, ACP, NCI, AAFP, ACPM, and the USPSTF) recommend that health care professionals discuss the possible benefits, side effects, and questions about early prostate cancer detection and treatment so that men can make informed decisions taking into account their own situation and risk.” (source: American Cancer Society)

How useful is a PSA for prostate cancer screening?

Sensitivity: 70-80%

Specificity: 60-70%

If you chose to order a PSA for prostate cancer screening:

The AmericanCollege of Physicians in addition to several other professional societies and task forces emphasize the need for shared decision making.

“Rather than screening all men for prostate cancer as a matter of routine, physicians should describe the potential benefits and known harms of screening, diagnosis, and treatment; listen to the patient's concerns; and then individualize the decision to screen.”(American College of Physicians)

Risks of prostate biopsy

  1. Physical discomfort
  2. Urinary tract infection, urosepsis
  3. Hematuria, hemospermia
  4. Urinary retention
  5. 1% of men have risks which require hospitalization
  6. High anxiety level because of high false negative rate

Risks of radical prostatectomy

  1. Operative mortality rate is 0 .5%
  2. urinary incontinence, (15-50%)
  3. sexual dysfunction (20%-70% of patients)
  4. bowel problems.

Risks of external beam radiation

  1. Erectile dysfunction in 20 to 45 percent of men with previously normal erectile function,
  2. Urinary incontinence in 2 to 16 percent of previously continent men,
  3. Bowel dysfunction in 6 to 25 percent of men with previously normal bowel function
  4. Prostatorectal fistula.

More detail as of July 2009

Recommendation

The United States Preventive Services Task Force Guidelines
/ Age <75 years, the benefits of screening for prostate cancer are uncertain and the balance of benefits and harms cannot be determined.
Age >75, there is moderate certainty that the harms of screening for prostate cancer outweigh the benefits.
Found convincing evidence that treatment for prostate cancer detected by screening causes moderate-to-substantial harms, such as erectile dysfunction, urinary incontinence, bowel dysfunction, and death. These harms are especially important because some men with prostate cancer who are treated may never have developed symptoms related to cancer during their lifetime.
There is also adequate evidence that the screening process produces at least small harms, including infection, pain and discomfort associated with prostate biopsy and psychological effects of false-positive test results
Canadian Task Force on the Periodic Health Examination / Recommends against screening for prostate cancer with PSA
American Urologic Association
/ Prostate cancer screening leads to over detection and overtreatment of some patients. Therefore, the AUA supports that men be informed of the risks and benefits of prostate cancer screening before biopsy
American Cancer Society
/ At this time, routine screening should not be recommended for all men. Rather, these early findings support the recommendation that men should make informed decisions based on available information, discussion with their doctor, and their personal perspectives on the benefits and side effects of screening and treatment
AmericanCollege of Physicians / Rather than screening all men for prostate cancer as a matter of routine, physicians should describe the potential benefits and known harms of screening, diagnosis, and treatment; listen to the patient's concerns; and then individualize the decision to screen

7. Prostatitis

Acute Bacterial:

  • Symptoms of chills, perineal and low back pain, dysuria, and occasionally bladder outlet obstruction. Tender and swollen prostate on digital rectal exam.

Chronic bacterial:

  • The most common cause of relapsing UTI in men.
  • Irritative voiding symptoms, pelvic pain, bilateral testicular pain.
  • Prostate may be tender or normal on DRE.
  • IVP and cystoscopy usually not indicated. Results in a relapsing UTI from the same organism.
  • Makes up only 10% of the prostatitises.

Non-bacterial:

  • The most common form of prostatitis.
  • The symptoms are the same as for bacterial prostatitis through the urine and expressed prostatic secretion (EPS) cultures are negative.
  • The EPS will show WBC’s
  • This condition is intermittent and will likely recur. Therefore, patient education is very important. Helpful remedies include:
  1. Increased water consumption
  2. Avoid straining when voiding
  3. Stress reduction techniques
  4. Warm sitz baths
  5. NSAIDs
  6. Decrease alcohol
  7. Decrease coffee
  8. Reassurance

Prostatodynia:

  • The findings and treatment are the same as for non-bacterial prostatitis though the EPS will show no WBC’s.
  • Antibiotics are not indicated! Use alpha blockers (Terazosin, Doxazosin, Tamsulosin)

The treatment of bacteria prostatitis:

  1. Treat with either Septra DS (BID), or Doxycycline (100mg BID), or Quinolones (Cipro, Levaquin) for 2 weeks for acture prostatitis and 8 weks for chronic prostatitis. Relapses are common. Sometimes the therapy needs to be extended to 12 weeks.
  2. Warm sitz baths prns.
  3. NSAIDs prn
  4. Inform the patient that the resolution of symptoms will be gradual, relapses are common
  5. Treat urinary retention as discussed in Bladder Outlet Obstruction.
  6. Refer treatment failures to Urology.

8. Renal Calculi