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)           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        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  67 year old male with increased nocturia  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  Drinks coffee and several sodas at night Case A Evaluation and Plan  Decrease fluid after dinner, dinner void before bedtime  Sono to determine residual. Consider adding ddi Proscar P if gland l d greater than h 40 grams  Make sure no hx of STD’s: stricture formation Case B  48 year old female with urgency and frequency. Hx of smoking  Failed ditropan 5 mg daily  Also complained p of stress urinaryy incontinence  Drinks lot of tea and coffee Case B Evaluation and Plan      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  40 year old female presents cannot void  N other No h physical h i l complaints, l i no h hematuria i  Non--smoker, non Non non--drinker  Exercises daily Case C Evaluation and Plan  Check sono and post void residual to make sure not dehydrated, R/O retention  Hx of energy drinks or drugs? BN spasm  Hx of stones or hematuria? Stone/clot / clog g  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  Transrectal needle biopsy of prostate (TRUS or finger guided) Evaluation of Elevated PSA       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  51 year old WM with PSA of 3.5, normal DRE  TRUS Bx of prostate negative for cancer  Repeat PSA still elevated, what to do next? Case A Evaluation and Plan     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  Sexually active  Medically healthy otherwise  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     81% 10 yr. survival Incontinence: < 5% ED: 45%  78% 10 yr survival  Proctitis, cystitis: 15%  ED: 4040-50%  Fistulas: 22--3%  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      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  Recommend surgery, discuss pros and cons of open vs vs. Robotic  Discuss risks of ED, SUI  Make sure partner is involved Case B  72 year old male with GS 7, 7 PSA 8  H off MI Hx MI, on thinners, hi otherwise h i h healthy lh  Not sexually active  Life expectancy 15 years Case B Evaluation and Plan  Consider radiation: compare external beam (daily for 15 minutes, 5 days/wk days/wk for a month  Brachytherapy, 1 ½ hours, OR, D/C in AM  Risks of recurrence,, cystitis, y ,p proctitis  Watchful waiting or consider surgery (> 15) Problem # 3 Erectile Dysfunction        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       “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  47 year old male with 6 month history of ED  Ph i ll fi Physically fit, nonnon-smoking, ki married i d 20 yrs  Stress at work and home. Has morning erections  Good libido libido, normal serum testosterone Case A Evaluation and Plan  Could try PDE5i PDE5i, make sure he is educated about the usage: empty stomach, no alcohol, must be aroused, aroused may need several attempts  P h l i l IIntervention? Psychological i ? (AM erections) i )  If testosterone was low, can add hormone supplement, pp , can salvage g 35% of failures Case B  58 yo overweight male w 2 year hx of ED  T ll you h Tells he h has tried i d all ll three h PDE5i w failure  Hx of high g blood pressure, p , diabetes & smoking  Happily married Case B Evaluation and Plan  Lose weight! Adipose tissue converts testosterone to estrogen  Stop smoking! #1 preventable/reversable preventable/reversable cause  Re--educate about PDE5 Re PDE5--i therapy: empty stomach, up to 55-6 attempts, arousal Case B Evaluation and Plan    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  52 year old WM on dialysis, on nitrates  Still smokes cigarettes  Getting married soon, wishes to correct ED Case C Evaluation and Plan     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       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  60 yo female had gross hematuria from “UTI”  It resolved when her UTI was treated with antibiotics ibi i  Smoked 2 PPD for 40 years  On blood thinners Case A Evaluation and Plan  Urine cytology  CT off abdomen bd and d pelvis l i w/ / and d w/o / contrast  Cystoscopy y py Case A Results  CT revealed l db benign i renall cyst  Cystoscopy revealed cystitis Case B  65 year old female with hx of smoking  G Gross and d microhematuria i h i  On thinners  No hx of trauma Case B Evaluation and plan  R exophytic lesion 5 cm  Contralateral kidney OK  No major j health issues Case B Evaluation and Plan      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  77 year old male with gross hematuria  H off prostate cancer 10 years ago, had Hx h d XRT  Symptoms of frequency, urgency, BOO  Worked in oil refinery business Case C Evaluation and Plan     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   Refer to urologist Cystoscopy reveals bladder tumor Problem # 5 Flank pain      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  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      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  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      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  [email protected] Questions Question # 1  PSA can be elevated due to:  UTI Prostatitis Ejaculation BPH All of the above N None off the h above b      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  [email protected]