Urology Flashcards
Imaging studies
- Gold standard for nephron/ureterolithiasis
- Good for physiology and anatomy of upper and lower tract
- hydronephrosis and small renal tumors
- upper tract in patients who are allergic to contrast or azotemic
- azotemic or dye allergy
- CT w/o contrast = gold standard for nephron/ureterolithiasis
- Intravenous pyelogram (IVP) = archaic, for physiology and anatomy of upper and lower tract
- Ultrasound = for hydronephrosis and small renal tumors; may miss ureteral and bladder tumors
- Retrograde pyelogram = for upper tracts in patients who cannot get contrast due to allergy or azotemia (but invasive)
- MRI = non-invasive alternative in azotemic or dye allergic patient
Imaging Studies
- US
- Retrograde urethrogram
- Cystourethrogram
- US = suprapubic mass, pelvic mass (rhabdomyosarcoma)
- Retrograde urethrogram (RUG) = catheterize up to distal urethra, instill radiopaque contrast and observe movement under fluoroscopic exam (real time x-ray) to assesses urethral strictures or disruption in setting of trauma.
- Voiding cystourethrogram (VCUG) = catheterize bladder, instill radiopaque contrast and observe movement under fluoroscopic exam (real time x-ray) to assesses obstruction (posterior ureteral valves, hydrocele, external mass) and reflux
Male Genitalia Anatomy
(fascia)
Male Genitalia Anatomy
(lateral)
median raphe is the line that runs on the ventral side of the penis shaft (on bottom)
Female Genitalia Anatomy
Vulva = EXTERNAL genitals
Vagina = MUSCULAR TUBE between vulva and cervix
Neonate hydronephrosis - management steps
Neonate hydronephrosis (US) = catheterize to ↓ pressure => imaging
Obese poorly controlled type 2 diabetes female in ER w/urinary urgency, frequency, fever, chills, n/v. Last week pt treated w/ empiric outpatient abx for UTI. PE showed R CVA tenderness. Labs showed leukocytosis & hyperglycemia. CT abd./pelvis showed gas in R renal parenchyma w/o extrarenal extension. Whats most important RF for emphysematous pyelonephritis?
- Urethrolithiasis obstruction
- Urethral obstruction from renal papillary necrosis
- Obesity
- Multi drug resistant bacteria
- Diabetes Mellitus
Emphysematous pyelonephritis = Necrotizing infection w/gas production mc due to E.coli or K.pneumoniae.
- DM is major RF for emphysematous progression of UTI
- Tx for emphysematous pyelonephritis w/o extrarenal involvement = percutaneous nephrostomy & IV abx
47 yo male w/ hx of nephrolithiasis present to ED w/ acute left flank pain, n/v. Vitals stable, writhing in pain. PE shows L CVA tenderness. Labs show hematuria. CT reveal 12 mm obstructing calculus of left UVJ. Whats next step?
- Microscopic urinalysis to exclude red cell cast
- Consult urology
- Provide pain control, start NS IV hydration, and advise pt to strain urine
- Admit to medicine service for pain control
- Provide IV morphine for pain control
- Microscopic urinalysis to exclude red cell cast = not needed for this
- **Consult urology = sepsis, ARF, anuria, pain unresponsive to medications, n/v, stone ≥ 10mm
- Provide pain control, start NS IV hydration, and advise pt to strain urine = stones ≤ 5 mm will pass spontaneously
- Admit to medicine service for pain control = unlikely to pass ≥ 10mm
- Provide IV morphine for pain control = unlikely to pass ≥ 10mm
12 yo boy w/progressive testicular swelling. Shows varicoceles. Whats most common complication?
- Testicular torsion
- Epididymitis
- Infertility
- Malignancy
- Deep venous thrombosis
- Impaired drainage of L internal spermatic vein into L renal vein => venous pooling => testicular vein & pampiniform plexus dilation => testicular varicoceles => increase temperature & impaired BF => infertility
- IVC thromboses => DVT => may rarely cause varicocele
Functional incontinence
- psychological unwillingness or physical barriers that deter person from using bathroom. Eg. dementia (primary neurologic process that limits mental capacity to decide to use bathroom)
Stress Incontinence
loss of bladder function often precipitated by ↑ intraabdominal pressure (laughing/coughing/strenuous activity).
- Mc in females w/↑ age and after vaginal births
- variable volume
- Tx = pads, bulking agent injections, slings, artificial urinary sphincters (men)
Overflow incontinence
detrusor sphincter dysynergia +/- anatomical abnormalities that obstruct outflow. Eg. enlarged fibroid uterus or prostatic hypertrophy
- Tx = lifestyle, pelvic floor muscle training, bladder training, surgery or medication to remove obstruction
Urge incontinence
strong & often sudden need to void 2ndary to bladder spasms/contractions. May be seen in cystitis related to UTI, stones, or neoplasm.
- Tx = behavioral modifications (lifestyle, pfmt, bladder training) => medications => refer to urologist (Sacral neuromodulation, peripheral tibial nerve stimulation, intradetrusor botox)
BPH Meds
Goals = ↓ smooth muscle (bladder neck “internal sphincter”, prostate, BP) and ↓ prostate growth
- Stress = Epi/NE => adrenergic R => ↓ rest/digest
- Alpha blockers (zoro to the rescue) = Doxazosin, Terazosine, Tamsulosin (Flomax)
- Immediately relieve sxs
- SE = asthenia, somnolence, hypotension, dizziness, fatigue, abn. ejaculation, nasal congestion/rhinitis
- Alpha blockers (zoro to the rescue) = Doxazosin, Terazosine, Tamsulosin (Flomax)
- Prevent Testosterone => DHT => ↓ DHT => ↓ Prostate growth
- Type II 5alpha reductase inhibitor (urethral ride) = Finasteride (proscar), dostasteride
- ↓ acute urinary retention & Transurethral resection of prostate (TURP)
- SE = testicular pain, impotence, ↓ ejaculation/dysfunction, ↓ libido, gynecomastia, breast tenderness, hypersensitivity
- Type II 5alpha reductase inhibitor (urethral ride) = Finasteride (proscar), dostasteride
- Best = Finasteride + Doxazosin
- BPH + OAB = add Anticholinergic (Tolderodine)
BPH indications for surgery
- Acute/chronic retention
- Recurrent UTI/hematuria
- Bladder stone/renal insufficiency due to BPH
- Lg bladder diverticulum
BPH minimally invasive surgeries
- Laser
- Transurethral electrovaporization/microwave thermal/radiofreq
- ↑ intensity focused U/S
- Urethral stent
BPH invasive surgeries
- TURP (resection of prostate) = GOLD STANDARD
- TUIP (incision of prostate)
- Open Proctectomy
Ketoconazole
antiandrogen for metastatic prostate ca. Inhibits steroid synthesis => ↓ Steroid production by adrenal glands and gonads.
- Also tx fungal infections (not BPH)
Slidenafil
“slide easy” inhibits phosphodiesterase type 5 => increase cGMP => ↑ NO => vasodilation => ↑ BF to corpus cavernosum. Tx erectile dysfunction (Viagra)
- Also tx pulmonary HTN
- Contraindicated = pts using nitrates due to risk of hypotension
Flutamide
antiandrogen for metastatic prostate ca. Flutamide + GnRH analog (given continuously) to prevent further sxs from initial hormone surge due to initial effects of GnRH analog.
- Not tx BPH
Finasteride
“urethra ride” shrink prostate via 5a reductase inhibitor (can also tx male pattern baldness)
SE = ↓ libido & ejaculation volume
Leuprolide
GnRH analog for metastatic prostate ca (given continuously) inhibits further production of LH => ↓ Testosterone.
- Also tx infertility if given in pulsatile fashion acts as an agonists; can also be used for uterine fibroids, endometriosis, and precocious puberty. (NOT BPH)
Vesicourethral Reflux (VUR) definition
- Backflow of urine from bladder => kidneys => frequent nephritis, kidney scaring & damage
- Caused by
- Congenital (primary) = mc VUR, caused by ureter valve defect (inheritable). Presents shortly after birth
- Obstructive (2ndary) = bladder/urethra obstruction caused by survery, injury, abnormal voiding, past infection that puts pressure on bladder. Presents at any age, mc in children w/birth defects such as spina bifida
VUR sxs
- UTI sxs most common (1/3 children w/UTI have VUR)
- Fever +/- dysuria, frequency, incomplete void feeling
- Suspect UTI if child has high fever w/o obvious cause
VUR dx
- VUR is dx when UTI is suspected
- Urinalysis => Urine culture – check for UTI
- US – shape and size but can’t detect reflux
- Cystourethrogram (cystogram) – post UTI tx, dx VUR (fills bladder w/dye and then x-ray images of bladder filling & voiding)
VUR grading
Using cystogram
- Grade 1 = urine back into ureter
- Grade II = urine back into renal pelvis & calyces
- Grade III = urine back into collecting system, mild ureter and pelvic dilation w/mild calyces blunting
- Grade IV = urine back into collecting system, moderate ureter and pelvic dilation w/moderate calyces blunting
- Grade V = urine back into collecting system, severe ureter and pelvic dilation w/severe calyces blunting
- Grade IV-V = indicated for surgery
VUR tx
- Mild cases spontaneously grow out of it by age 5 & do not require tx
- If tx is needed abx (amoxicillin or trimethoprim-sulfamethoxazole (BACTRIM)) – prophylactically or as needed
- Severe cases or recurrent UTI while taking abx will require surgery (create new valve)
VUR surgery indications
- Grade IV-V
- Persistent reflux despite medial tx (>3)
- Breakthrough UTIs w/receive abx prophylaxis
- Lack or renal growth
- Multiple drug allergies the prevent them to use abx
- Medical noncompliance
59 yo w/dysuria, mild fevers (100.3F), lower back pain. No urethral discharge, no testicular pain. DRE reveals tender & enlarged prostate gland
- Prostatitis
- Cystitis
- Pyelonephritis
- Orchitis
- Urethritis
- Prostatitis = urine reflux => tender enlarged prostate, fever
- mc UTI (gram neg = E.coli, Proteus, Klebsiella, Enterobacter, Pseudomonas), STI less likely
- Acute cystitis = frequency, dysuria, urgency, nocturia, fever less prevalent
- Acute pyelonephritis = more dramatic presentation, high fever, chills, flank pain + urinary sxs
- Orchitis = epididymitis (STI)/viral => orchitis => heavy aching testis, frequently enlarged, not present w/ urinary sxs,
- Urethritis = STI => urethral discharge, dysuria, frequency (Chlamydia = watery, Gonorrhea = thick)
68 yo male hx of nocturnal urination present to ED w/ hx of urgency, frequency, fever, chills. PE show no CVA tenderness, and declined DRE. Labs show ↑ PSA. Most likely cause of sxs?
- UTI
- Pyelonephritis
- Nephrolithiasis
- Acute prostatitis
- Prostate CA
- UTI = does nt present w/systemic sxs (fever/chills)
- Pyelonephritis = less likely since no CVA tenderness
- Nephrolithiasis = present w/localized sxs, unlikely to be bilateral
- Acute prostatitis = fever, chills, malaise, myalgia, dysuria, pelvic or perineal pain, cloudy urine. Tender & edematous prostate.
- Isolated acute cystitis does not common in men! Virtually all UTIs in mend are due to prostatitis. Mc = E. coli & proteus (gram -)
- RF = BPH, GU instrumentation predispose pts for UTI
- Early tx prevent prostatic abscess & sepsis
- Prostate CA = elevated PSA more likely due to acute prostatitis, derfer serum PSA evaluation for a month after acute prostatitis
Female 12 wks pregnant presents for routine prenatal visit. Patient feels well, vitals normal, PE unremarkable. Urinalysis + for nitrates & leukocyte esterase. Prompt urine culture grows E.Coli. Management?
- No tx bc asymptomatic
- Renal US
- Admission + IV abx
- Repeat urine culture
- Oral abx + short interval FU
- No tx bc asymptomatic = WRONG
- Renal US = for serious infections like pyelonephritis or to look for complciations cush as hydronephrosis or abscess
- Admission + IV abx = for serious infections like pyelonephritis
- ***Oral abx + short interval FU = 10% pregnant women present asymptomatically and UTI is associated w/ preterm & low birth weight.
53 yo male w/HTN, gout, DM type 2 in ED w/acute left flank pain. In ED distressed w/acute L flank pain. Vitals stable, PE L CVA tenderness, Labs gross hematuria in urinalysis.
- Renal US
- Abdominal radiograph (upright)
- Abdominal/Pelvic CT scan
- Renal stone protocol CT
- Renal US = renal calculi & unilateral hydronephrosis consistent w/ obstructing calculus, but can’t image entire ureters. It is first line for pediatric or pregnant
- Abdominal radiograph (upright) = large radiopaque stones, miss uric acid stones, small stones, or stones overlying bony structures.
- Abdominal/Pelvic CT scan = visualize calculus but inferior to renal stone protocol.
- Renal stone protocol CT = noncontract helical CT, reduce dosage & position in prone to remove deponent bladder calculi from UVJ to prevent misstating freely mobile bladder calculus for UVJ obstructing stones.
Emphysematous pyelonephritis
diabetic, unilateral flank pain, 103.5 F (high fever), low BP
- Dx = CT shows air in renal parenchyma
- Tx = medical emergency, rapidly fulminating – moderate/severe cases req emergent nephrectomy
Pyelitis
collecting system (renal pelvis & ureter w/o renal parenchymal involvement) inflammation
- Caused by infection or stone disease, no gas present
Obstructive uropathy
dilated collecting system, w/clear source of obstruction (mass, stricture, stone)
Renal lymphoma
focal renal mass/diffuse parenchymal infiltration/perirenal adenopathy
- Chronic process
Renal Tuberculosis
rare, w/nonspecific imaging in acute stage, resembles non complicated pyelonephritis w/low density adenopathy. In chronic cases, chronic renal failure w/atrophic & scarred kidney +/- dystrophic calcifications
Pyelonephritis
- Cause
- HPI/PE
- Labs/Orders
- Tx
- delayed UTI tx => ascending UTI or Ureteral flow obstruction (paritipartialucting calculus)
- Microbes = E. coli (75-95%), Proteus, K.pneumoniae
- UTI sxs, fever, unilateral CVA tenderness
- Sepsis, acute renal failure, vague sxs (malaise/abdominal pain)
- Labs/Orders
- Urinanalysis (visual, dipstick, microscopic)
- infection = > 20 WBCs/hpf & 100,000 CFU & white cell casts
- Urine culture
- CT & US evaluate underyling anatomic abnormailites or detect complications (calculus, abscess)
- Urinanalysis (visual, dipstick, microscopic)
- Complicated pyelonephritis = admitted & given parenteral, broad-spectrum abx, then narrowed after urine culture. Abx administered 10-14days.
Normal & Abnormal Urine crystals
- Needle-shaped = uric acid
- Bipyramidal & biconcave crystals = calcium phosphate/oxylate
- Coffin-shaped (rectangle) = staghorn
- Hexagon = cystine
Kidney stones types
- Type
- Population
- Circumstances
- Color
- Sensitivity
- Details
7.
alkaline pH = staghorn, calcium phosphate
acidic pH = calcium oxalate, uric acid,
Normal urine analysis
56 yo male w/hematuria dx with bladder cancer. Previously worked in rubber tire factory for 25 yrs. What carcinogen puts him at greatest risk?
- aromatic amines
- alkylating agents
- polycyclic hydrocarbons
- aflatoxin B1
- nitroamines
-
Aromatic Amines from rubber & analine dye industry => bladder ca.
- Bladder CA risk factors, Φ familial syndrome
- Environmental = Smoking, chemical exposure (aniline dyes, aluminum, paint, petroleum, rubber, textiles), diet rich with meat & fat.
- Iatrogenic = Pelvic radiation, Cyclophosphamide (CXT), Chronic cystitis (indwelling catheters)
- Geography = Africa/Middle east => Schistosomiasis (snails) => Squamous cell bladder cancer
- Bladder CA risk factors, Φ familial syndrome
- Alkylating agents = chemo agent (cyclophosphamide & chlorambucil) used to tx variety of cancers. Does not increase risk of 2ndary malignancy due to their effect on changing DNA structures.
- polycyclic hydrocarbons = produced after tobacco combustion => lung ca
- aflatoxin B1 = fungal sp (aspergillus flavus) on grains & peanuts ingestion in mostly Asia => hepatocellular carcinoma
- nitroamines = food perservatives, salted meats, pickled foods common in asia => gastric carcinoma and GI ca.
77 yo male in ED can’t void.
Hx nocturnal frequency w/weak stream.
PE distended bladder, enlarged, multi-nodular non-tender prostate.
Dx?
- Prostatitis
- Prostate CA
- Cystitis
- Chronic bladder outlet obstruction
- Renal Failure
- Prostatitis = urine reflux w/G- => fever, pain, prostate tenderness
- Prostate ca = peripheral => silient, rarely grows to completly obstruct urethra => elevated PSA. If palpable, hard nodule.
- Cystitis = rarely in men, same mec as prostatitis => hematuria and Lower tract sxs but not painless urinary retention
- Chronic bladder outlet obstruction = sxs are classic for prostatic hyperplasia. Nodular contour can be 2ndary to BPH nodules.
- Renal failure = would cause acute rather than chronic sxs. Bladder would be minimally distendend
12 yo in ED w/ acute hematuria after hockey game. PE unremarkable.
Urine dipstick & urinalysis = red color, pH (6.2), specific gravity (1.024), glu (-), blood (+4), protein (trace), Nitrate (-), Leukocyte esterase (-), wbc (o/hpf), rbc (2/hpf).
Most likely cause?
- Glomerulonephritis
- Myoglobinuria
- Hematuria
- Trauma
- UTI
Blood in Urine dipstick may represent hemoglobin or myoglobin. Myoglobin can be elevated post exercise and is benign.
- Glomerulonephritis = paucity of RBC, no rbc casts
- Myoglobinuria = If dipstick shows + for blood, perform microscopic analysis.
- Hematuria = paucity of RBC
- microscopic hematuria = > 3 RBC/hpf
- Trauma = low RBC count, no hx of trauma
- UTI = no WBCs and neg. leukocyte esterase
Pt w/nephrolithiasis due to calcium oxalate stones. What diuretic can be used?
- Acetazolamide
- Hydrochlorothiazide
- Furosemide
- Triamterene
- Spironolactone
- Acetazolamide = carbonic anhydrase inhibitor, minimal effect on renal Ca+
- Hydrochlorothiazide = Thiazide diuretics are the only class that decrease urinary secretion of Ca+
- Furosemide = loop diuretic. Blocks action of Ka, K, 2CL cotransporter. Causes inc. Na, K, Ca in urine => inc. stone production
- Triamterene & Spironolactone = K+ sparing diuretics. Block Na/K exchange in collecting duct, decrease K+ secretion, but elevate Na+ & Ca2+ secretion => inc. stone production
Diuretics
Retain (in body), Secrete (in urine)
-
Acetazolamide
- Retain = creatinine, abx, diuretics, uric acid
- Secrete = carbonic anhydrase (NaHCO3), glucose, AA
-
Osmotic = Mannitol
- Retain = water
-
Loop diuretic = Furosemide, Bumetanide, Torsemide, Ethacrynic Acid
- Secrete = Na+, K+, 2Cl- (cotransporer blocked) => Mg2+, Ca2+, K+ (dragged by cotransporter)
-
Thiazide = Chlorothiazides
- Retain = only class that decrease urinary secretion of Ca+
- Secrete = Na+,Cl-
-
Aldosterone antag “K+ sparing diuretics” = Amirloride, Triamterene, Spironolactone
- Retain = K+
- Secrete = Na+, Cl- (Block Na/K exchange), Ca2+ follows Na+
28 yo overweight female w/ hx of poorly controlled type 2 diabetes presents in ER w/ urinary urgency, frequency, fever, chills n/v. Pt failed empiric outpatient tx for UTI last week. PE + CVA tenderness. Labs + leukocytosis, hyperglycemia. CT abd/pelvis + gas in left renal parenchyma w/o extra-renal extension. What’s next step of management?
- IV abx & Interventional radiology consulation for percutaneous nephrostomy
- Surgical consultation
- Hospital admission & abx PO
- Extended abx PO
- Hospital admission & parenteral abx
This is emphysematous pyelonephritis is a necrotizing infection w/gas production involving renal parenchyma, and in some cases perirenal tissue.
- emphysematous cystitis & pyelitis (gas in renal pelvis) can also ocur
- infection usually due to E.coli, K.pneumoniae
- DM major risk factor of UTI to progress to emphysematous pyelonephritis
- IV abx & Interventional radiology consultation for percutaneous nephrostomy = pts w/emphysematous pyelonephritis w/o extra-renal involvement
- Surgical consultation (nephrectomy or open drainage) = pts w/extra-renal involvement or fail IV abx w/percutaneous nephrostomy.
- Hospital admission & abx PO; Extended abx PO = oral abx not sufficient for pyelonephrtis
- Hospital admission & parenteral abx = pts w/emphysematous pyelitis
60 yo male w/recent onset dysuria. PMH of BPH. ROS of occasional hesitancy, and nocturia. No other significant PHM. Vitals normal. PE remarkable for suprapubic tenderness, otherwise non-contributory. Urinalysis + leukocyte esterase & nitrites.
What’s the management?
- start oral abx
- admit for IV abx
- PerfumPerform US
- PerfomPerformCT
In older men BPH => bladder outlet obstruction => UTI
- Oral abx = UTI (longer abx course than women)
- admit + IV abx = pyelonephritis (high fever, flank pain, rigors, eventually sepsis) this is a medical emergency
- US & CT = complications of cystitis or pyelonephrtis (eg abscess)
Lower Urinary tract sxs
LUTS = obstructive and irritative sxs (occur in both sexes with age)
- Obstructive sxs WISE = Weak stream, Intermittent stream, Strain, incomplete Emptying
- Urethral strictures
- Irritative sxs FUN = Frequency, Urgency, Nocturia
- Bladder tumors
- Both = BPH
Anatomy, histology, physiology of Prostate Gland
- BPH site and sxs
- Prostate ca and sxs
Nl prostate secretes enzymes (PSA) that liquefy semen & enlarges with age.
- Anterior zone = fibromuscular & non-glandular
-
Peripheral zone = acinar => carcinoma
- Close to rectum, felt during DRE
- LUT sxs only in late phase, hard & firm prostate
- Central zone = proximal urethra, internal urethral sphincter
-
Transition zone = urethra => BPH
- Around urethra, not easily felt during DRE
- LUT sxs, rubbery smooth or nodular prostate
BPH Etiology
Most men by age 80 have enlarged prostate which is normal. BPH can cause retention => recurrent UTI => bladder/renal calculi, hydronephrosis => kidney damage
BPH: HPI & PE
HPI
- Aging => epithelial & smooth muscle hyperplasia in Transition Zone (BPH) => obstructs urethra => lower urinary tract sxs (LUTS)
- LUTS = obstructive (WISE) and irritative (FUN) sxs
- +/- Hematuria
PE
-
DRE = rubbery, uniform enlargement = BPH transition zone => +/- detectable on DRE
- hard/irregular lesion = prostate ca mc peripheral => detectable on DRE
- Neurologic = normal sphincter tone, perineal sesnation, and sacral reflexes (knee & ankle jerks)
BPH: WU
- Family Practice
- Urologist
-
International Prostate Symptom (IPSS)
- 0-7 mild
- 7-15 moderate
- >15 severe
-
UA & Urine culture to rule out infection & hematuria
- Hematuria (>3 RBC/hpf) on urine microscopy w/o infection => refer to urologist for hematuria WU to rule out ca
- Voiding diary
- Serum Creatinine to rule out obstructive uropathy & renal insufficiency
At Urologist
-
Uroflowmetry (measure urine flow rate) = assess severity of BPH
- Low flow rate (<10 cc/sec) = urethral obstruction (BPH, stricture, tumor) or poor bladder contractility
-
Postvoid Residual (PVR) = assess incomplete emptying or urinary retention
- catheter placed post void & measured w/US (not very reliable)
- Low PVR (<50 cc)canrule out incomplete emptying or urinary retention
-
Urodynamic (cystometry, pressure-flow analysis) = assess compacity, compliance, contractility of bladder/ degree of obstruction/ neurologic
- Indications
- Rx refractory BPH, considering surgical tx
- Neurologic etiology (spinal cord injury, prolapsed lumbar disk, etc.)
- Indications
BPH: Management
- IPSS = 15
- UA = no infection or hematuria
- PVR = 15 cc
- 1st line = Alpha (adrenergic) blockers => relax smooth muscle => open prostatic urethra
- Terazosin (2mg PO QHS, over few wks, increase dose to 8-10mg), Doxazosin, Tamsulosin (flomax)
- SE = Dizziness, HA, Fatigue, Nausea
- Decongestants (Sudafed = pseudoephedrine) is adrenergic agonists => increase LUTS
- 2nd line = 5a-reducatase inhibitors => reduce dihydrotestosterone production => reduce acinar-glandular volume
- Finasteride - Proscar
- Reserved for LARGE prostate, and takes 6 mos to shrink volume
BPH: Managment
- IPSS = 15
- UA = no infection or hematuria
- PVR = 15 cc
- On alpha blocker but sxs not improve much
- Perform Urodynamic evaluation - confirms sxs are due to obstruction not from neurologic problems or poor contracting bladder
- 3rd line = Surgery
- Indications = Rx refractory, recurrent urinary retention, obstructive uropathy or bladder stones from bladder outlet obstruction, desire to avoid meds.
- Transurethral resection of prostate (TURP) = gold standard for prostatic obstruction from BPH
- Transurethral Microwave thermotherapy (TUMT) = less effective, use for cardiac risk/co-morbidities
- Transurethral radiofrequency needle ablation of prostate (TUNA) = less effective, use for cardiac risk/co-morbidities
- Open simple prostatectomy = very large prostates > 100 grams or bladder damaged/stones, does not remove entire prostate
- Open radical prostatectomy = NOT for BPH, only for prostate ca
A male with baseline prostatic obstruction (Benign Prostatic Hyperplasia or BPH) and/or reduced bladder contractility is at risk of acute urinary retention. By a variety of mechanisms. List 7
- Prostatitis = prostatic edema & swelling => increase bladder outlet resistance
- Narcotics = reduce bladder contractility
- Diphenhydramine (Benadryl) = anti-histamine with significant anti-cholinergic effects => reduce bladder contractility
- Pseudoephedrine (Sudafed) = sympathomimetic => stimulate alpha receptors in prostate => increase resistance at prostatic urethra
- Oxybutynin (Ditropan) = strong anti-cholinergic used to tx bladder spasms and over activity. Men should generally not be given this medication without consulting a urologist. Tolterodine (Detrol) is a similar medication.
- Alcohol ingestion = trigger urinary retention; the exact mechanism is not clear.
- General and particularly Spinal Anesthesia = paralyze bladder which often results in post-op urinary retention.
Acute urinary retention due to BPH: Management
- Decompress bladder = catheterize and drain urine (nl bladder holds 500 cc)
- RU serious obstructive uropathy = measure creatine (nl .6-1.2 mg/dL)
- Tx = Start alpha blocker
-
Assessment/Plan = Refer to urologist for voiding trails in 3-7 days.
- alpha blockers require 72 hrs to reach optimal levels and allow bladder to recover muscle contractility
- 50% will pass the voiding trial after an episode of acute retention, thus avoiding TURP
- Suprapubic tube provides no added benefit compared to urethral catheterization
- Mildly elevated serum creatinine is fine, it will drop to normal post decompression
- Finasteride (takes 6 mos) not helpful in acute setting
- All men w/ retention should be referred to urologist for FU
Acute urinary retention due to BPH: Management
- 2,000 cc bladder urine
- Creatinine 3.1 mg/dl
> 1,000 cc urine & elevated creatine are at risk for post-obstructive diuresis
- Diagnostic POD = urine production…
- > 3L/24hrs
- > 200 mL/hr for 2 consecutive hours or
- Treatment is the same
- Decompress = urethral catheterization (foley)
- Replacement fluids (limit to 75% of prev. hourly urine output until polyuria normalized) & Monitor (serum & urine electrolytes)
- Alpha blockers + 5 alpha reductase inhibitors
- Refer to urologist in 7 days = void trial (more likely to fail)
BPH: Recurrent urinary retention or failed voiding trail tx
- surgery = TURP, laser TURP, Urolift
- Long term intermittent self catheterization (permanent. foley catheter) or supapubic (S/P) tube = severely damaged or atonic bladders
Leading cause of cancer death in men x 5
- lung ca
- prostate ca
- colorectal ca
- pancreatic ca
- liver & biliary duct
Prostate ca: Etiology
MC ca & 2nd leading ca death (after lung ca) in men
Age, + FH, African Americans
PSA
- Causes of PSA elevation
- PSA values
- False + = cystoscopy, bx, BPH, UTI, prostatitis, Ejaculation
- PSA values
- Absolute PSA reference = 40’s (2.5ng/mL) - 70’s (6.5ng/mL)
- 10ng/mL = likely to metastasize
-
PSA density = prostate volume/absolute PSA levels (volume measured by TRUS or MRI)
- ≥.15ng/ml indication for bx
-
PSA Velocity = 3 measures obtained over 2 yrs
- .35ng/ml/yr rise if <4ng/ml
- .75ng/ml/yr rise if >4ng/ml
-
Free PSA
- < 10% indications for bx
- Absolute PSA reference = 40’s (2.5ng/mL) - 70’s (6.5ng/mL)
Prostate ca: HPI & PE
HPI = slow-growing malignancy, stepwise disseminates (prostate => pelvic lymph nodes => spine and pelvic bones)
- Early/local = Asymptomatic (not tender), DRE hard/irregular lesion (late), elevated PSA
-
Advanced/metastatic
- Locally advanced (spread beyond prostate) => LUTS
- Retroperitoneal (adenopahty d/t nodal mets) => Lower extremity edema (Obstruction lymphedema)
- Low back pain w/wo pathologic fx (mets to bone) => elevated alkaline phosphatase, PSA, PAP
PE
- DRE - most ca found w/normal DRE
- Normal rectal findings: 3-4 cm, non-tender, symmetric, smooth, rubbery, walnut shaped prostate; Strong sphincter tone, no rectal mass; Heme (-) stool
- Abnormal = enlarged, non-tender, irregular/asymmetric, hard, nodule(s)
- Complete exam
- Distended bladder (outlet obstruction)
- Bone pain
- Lower extremity lymphedema or DVT
- Neurologic due to cord compression
- Cachexia
Prostate ca: Screening
- American Academy of Family Physicians (2012)
- American Cancer society (2010)
- American college of physicians (2013)
- American urological association (2013)
- US prevention
DRE screening, generally 50-55 yo
PSA screening = Always shared decision making for
- American Academy of Family Physicians & US prevention = No PSA or DRE
- American Cancer society (2010) = 50 yo (45 yo for high risk)
- American college of physicians (2013) = 50-69 yo w/life expectancy > 10 yrs
- American urological association (2013) = 55-69 yo w/life expectancy > 10 yrs (40 yrs for high risk)
Prostate ca: WU
- Labs
- LUTS = always check PSA
- Asymptomatic = check PSA if screening is indicated
- CBC, chemistry profile (alk phos), LFT
- UA, Urine culture
- Trans-rectal US (TRUS) guided Bx (diagnostic)
-
Indications + DRE and/or + PSA
- + DRE = enlarged (>4 cm) or asymetric/nodular or firm
- PSA = age specific increase > 4 ng/mL, % free < 15%
-
TRUS bx = Gleason Pathologic staging mc adenocarcinoma (glands)
- Score < 8 = less aggressive
- Score 8-10 = aggressive
-
Indications + DRE and/or + PSA
-
Imaging = Bone scans, CT scans, MRI scans
-
Indications high risk (1 of following)
- PSA > 10ng/dl (spread to seminal vesicles)
- Poorly differentaited (Gleason 8-10)
- DRE stage ≥ T3
- inc alk.phosphatase or bone pain
-
Indications high risk (1 of following)
Prostate: progression
- Spread
- Gleason Grade
- TNM Staging
- Mets
- Step wise spread: prostate => pelvic LNs => spine => pelvic bones => direct extension to bladder (rare) or lungs (advanced)
- ca is slow to progress, tx depends on aggressiveness
- Gleason grade (sum of 2 most dysplastic samples 1-5; 3 + 5 = 8 better px than 5 + 3 = 8)
- TNM stage
- Bone scan for mets (osteoblastic or high bone density), CT, MRI, 40% met @ sxs presentation
Prostate ca: tx
64 yo male w/
- DRE = 1 cm nodule localized
- PSA = 4.6 ng/dl
- PSA volume = low
- Gleason 6
strongly suggest prostate cancer has not spread and is confined to prostate.
- 1)small localized nodule; 2) relatively low PSA (nl for 64 = 4.5ng/dl); 3)low volume; 4)Gleason 6 low aggressiveness
Tx for localized prostate ca
- Active surveillance = low volume, low risk (grade 1-6)
- Brachytherapy (seeding) = low-volume, moderately risks (grade 7). not an appropriate option for very large glands.
- Radical prostatectomy = < 75 yo old who is healthy & has > 10-year life expectancy
- External beam radiotherapy = older (>75 years old) and/or have major comorbidities.
Prostate ca: tx
64 yo male w/
- Post Radical prostatectomy
- PSA = 68 ng/dl
- Signs and symptoms of advanced & metastatic prostate cancer = elevated PSA, urinary retention, bone pain.
- Once metastasized local tx do not work
- 1st line = hormone therapy.
-
Medical castration (gold standard) = goserelin (Zoladex) & leuprolide (Lupron).
- High PSA (not pulsatile) tx of gonadotropin releasing-hormone agonists shut down sex-hormone axis => eliminate testosterone production
- Bilateral orchiectomy
-
Medical castration (gold standard) = goserelin (Zoladex) & leuprolide (Lupron).
- Later therapies = ketoconazole, prednisone, chemo, immunotherapy
Prostate ca: Tx side effects
- Local treatment
- Metastatic treatment
- both radical prostatectomy and radiation therapy (external beam and brachytherapy) => urinary incontinence and erectile dysfunction
- dec. libido, gynecomastia, etc…
Incontinence: Etiology
Etiology = Majority are mixed incontinence
- Bladder dysfunction
- Urge incontinence = detrusor overactivity (non-/neurogenic), poor compliance
- Overflow incontinence
- Urethral dysfunction
- Stress incontinence = anatomic (due to mobility of the bladder neck); intrinsic sphincter deficiency (due to bladder neck dysfunction)
- Transient causes “reversible” - DIAPPERS
- Delirium
- Infection
- Atrophic vaginitis
-
Pharmacologic
- sedatives (ROH, benzodiazepines),
- diuretics (overwhelm bladder volume & uninhibit detrusor contractions),
- anticholinergics (retention => frequency, overflow incontinence),
- a-adrenergic (bladder neck & proximal sphincter contraction *used to tx prostatism => retention),
- a-antagonists (smooth m. of bladder neck & proximal sphincter relax *used to tx HTN => exacerbate stress incontinence in women)
- Psychological (depression)
- Excessive urine production = ↑ intake, DM, hypercalcemia, CHF, peripheral edema => polyuria
- Restricted mobility
- Stool impaction
Incontinence: HPI/PE
HPI
- Sxs = urgency, frequency, nocturia, unable to reach the toilet with urge, leakage w/physical activity
- Characteristics of incontinence (stress, urge, pad use)
- Comorbid conditions (DM, depression, constipation, prolapse, atrophic vagina)\
- Medications
- Prior pelvic surgeries /radiation
- Pelvic prolapse sxs (recurrent UTI, vaginal fullness/pressure, see bulge in vagina)
PE
- pelvic exam = vaginal epithelium condition, bladder neck mobility, + stress test (patient coughing/straining => urethral leakage), pelvic organ prolapse
- both brief neurologic survey = rectal exam to evaluate sphincter tone & perineal sensation
Incontinence: WU
Urinalysis = hematuria, pyuria, glucosuria, or proteinuria.
- Cultured if there is pyuria or bacteriuria. Tx infection before further investigations/interventions.
Functional studies
-
Post void residual (PVR) = measured by ultrasound or direct catheter
- Normal PVR < 50 mL
- PVR > 200 mL w/urinary sxs => bladder outlet obstruction or poor bladder contractility – distinguish by functional urodynamic testing
- Voiding diary = quantitate amount of fluid intake/void, # of voids/incontinent episodes
-
Urodynamic testing = examine bladder compliance, detrusor overactivity, urethral function, rule out obstruction as a cause of either overflow or urgency incontinence.
- performed prior to invasive therapies and indicated in patients undergoing repeat procedures following failed treatments.
Incontinence: Tx for urgency
- 1st line = Behavioral Changes
- avoidance of bladder irritants
- timed voiding
- fluid management
- pelvic muscle exercises
- 2nd line = Medical Therapy
- alpha agonists (↑ smooth muscle tone in bladder neck and proximal urethra)
- anticholinergics (relax smooth muscle)
- beta 3 adrenergic receptor agonists
- 3rd line
- Botox
- Percutaneous tibial nerve stimulation
- Sacral neuromodulation
Incontinence: Tx for stress
- 1st line = Behavioral Changes
- timed voiding
- fluid management
- pelvic muscle exercises
- weight loss
- 2nd line = less invasive
- Pessaries
- Urethral bulking agents
- 3rd line = surgical
- Retropubic suspensions – Midurethral synthetic sling – Pubovaginal sling
Urge Incontinence (overactive bladder)
- HPI
- Tx
- Urge Incontinence (overactive bladder) = bladder pressure sufficient to overcome sphincter mechanisms
- Detrusor overactivity mc elderly +/- bladder outlet obstruction
- ↓ Bladder compliance due to viscoelastic loss in bladder/change in neural-regulatory activity
- Sxs = urgency, frequency, nocturia, unable to reach the toilet with urge
-
Tx = Overactivity (behavioral & ant-muscarinic), Compliance (decrease pressure by intermittent catheterization & anticholinergics +/- Botox)
- 1st line Behavioral = avoid bladder irritants, timed voiding, pelvic muscle exercises, weight loss
-
2nd line Anticholinergics – Antimuscarinics
-
Nonselective for M3 Receptor
- propantheline (Pro-Banthine) = 7.5 to 30 mg orally, three to five times daily
- tolterodine (Detrol LA) = 4 mg orally daily
- trospium (Sanctura) = 20 mg orally two times daily
- solifenacin (Vesicare) = 5 – 10 mg orally, daily
-
Selective for M3 Receptor
- darifenacin (Enablex) = 7.5 – 15 mg orally, daily
-
Smooth Muscle Relaxant
- oxybutynin
- regular (Ditropan) 2.5 to 5 mg orally, one to three times daily
- extended release (Ditropan XL) 5 – 30 mg orally, daily
- transdermal (Oxytrol) 4.9 mg patch twice per week
- hyoscyamine (Levsin) = 0.125 to 0.375 mg orally, two to four times daily
- oxybutynin
- Side effects = urinary retention, dry mouth, constipation, nausea, blurred vision, tachycardia, drowsiness and confusion, contraindicated for narrow-angle glaucoma.
-
Nonselective for M3 Receptor
- Surgical
- Neuromodulation w/sacral nerve stimulator/bladder augmentation = refractory
- Botulinum toxin injection = idiopathic, refractory OAB.