2/11/2014 Genitourinary Blueprint – 6% of Exam UROLOGY REVIEW “MUST KNOWS” FAPA 2014 Winter Symposium Jeanette Lain, MHS, PA Atlantic Urological Associates Deland, Florida GU Tract Infections Neoplastic Renal Fluid/Elect BPH Cystitis Bladder CA Acute Renal Failure Hypovolemia Congenital Abnormalities Epididiymitis/ Orchitis Prostate CA Chronic kidney disease Hypervolemia Cryptorchidis C t hidi m P t titi Prostatitis Renall Cell R C ll Carcinoma Gl Glomerulol nephritis Acid/base A id/b disorders ED Pyelonephritis Testicular Carcinoma Hydronephrosis Hydrocele Urethritis Nephrotic Syndrome Wilms Tumor Incontinence PKD Stones Vascular Phimosis Anatomy of Genitourinary System More Detailed Anatomy of GU System Female versus Male GU Anatomy Acute Cystitis – Bladder Infection Symptoms Etiology Lab Findings Treatment Irritative voiding Inflammed bladder UA:Pyuria, bacteriuria, hematuira 3 day course: Bactrim/Cipro Suprapubic pain Coliform bacteria or g o gram a ((-)) Culture (+) Ampicillin Cephelexin Cep ee Doxycycline Possible gross hematuria Usually ascends from urethra XR – only if complications Pyridium for bladder analgesic Often occur after intercourse F>M, due to location and length of urethra Cranberry supplement 1 2/11/2014 Acute Epididymitis Chronic Bacterial Prostatitis Symptoms Etiology Lab Findings Symptoms Etiology Lab Findings Treatment Follows acute physical activity, trauma or sexual Most are infectious CBC: leukocytosis Bed rest with scrotal elevation Nocturia, dysuria, frequency May evolve from acute bacterial prostatitis Culture: Causative agent Bactrim, cipro, doxycycline for 6 weeks Urethritis, urethral discharge 2 categories: <40 40 yo: STD >40 yo: UTI, prostatitis STD subtype: Gram stain:N. gonorrhea or C. trichomatis STD subtype: Abx for 10 10-21 21 days Treat partner Chronic perineal or suprapubic discomfort Caused by gram ((-)) rods (E. coli, Pseudomonas) Non STD subtype: UA: pyuria, bacteruria and hematuria Culture: causative agent Non STD subtype: Abx (Fluroquinolone) For 21-28 days Expressed Hot sitz baths prostatic secretion (EPS): increased leukocyte and lipid laden macrophages Irritative voiding symptoms Treatment Pain in scrotum Irritative voiding symptoms TURP Low Back Pain Anti-inflammatory agents Hx of chronic UTI Fever Scrotal swelling Non-bacterial Prostatitis Acute Bacterial Prostatitis Symptoms Etiology Lab Findings Treatment Symptoms Etiology Lab Findings Nocturia, dysuria, frequency Unknown: possible autoimmune EPS: positive Antimicrobials Fever, perineal, scaral or suprapubic pain CBC: leukocytosis Hospitalization Chronic perineal or sup o suprapubic apub c discomfort Possible interstitial te st t a cystitis cyst t s CBC: increased WBC C Antiinfammatories a ato es ONLY PROSATITIS WITH FEVER AND POSITIVE UA Treatment Irritative voiding symptoms Possible mycoplasma or ureaplasma Exquisite tenderness w/ DRE Caused by gram (-) rods (E. coli, Pseudomonas) UA: Pyria, bacteriuria, hematuria Ampicillin and aminoglycoside until cultures come back Low back pain Possible chlamydia Irritative voiding symptoms Route: ascent up urethra and reflux of infected urine into prostate Culture: causative agent Oral Abx: Bactrim or quinolones for 4-6 weeks Obstructive symptoms Pyelonephritis Classification of Urinary Incontinence Symptoms Etiology Lab Findings Treatment • Stress incontinence Fever, flank pain, shaking chills Infectious inflammatory disease of renal parenchyma and renal pelvis CBC: increased WBC Broad spectrum abx: aminoglycosides, ampicillin • Urge incontinence Nausea, vomiting, diarrhea Grossly enlarged kidney and full of pus UA: pyuria, bacteruria, hematuria Treat nausea, pain and vomiting Irritative voiding Gram (-) aerobic bacteria Culture: heavy growth of causative agent Hydration Tachycardia E. coli, Proteus, Pseudomonas, Klebsiella, Enterobacter XR: Enlarged kidney Repeat culture 46 months Pronounced CVA t d • Total incontinence • Overflow incontinence • Mixed incontinence • Combination of two or more of above Failure: CT for t 2 2/11/2014 Normal Urinary Tract Stats Stress Incontinence • Bladder capacity 400-600 ml Symptoms • Bladder filling pressure 10cm H2O Involuntary loss of Most common in urine during women, rare in activities men • Male voiding pressure 50-75 cm H2O • Female voiding pressure 30-50 cm H2O • Male Urine Flow 15-25 ml/s • Female Urine Flow 30-35 ml/s • Urethral pressure 20 cm H2O Etiology Topical estrogen (Estrace cream, premarin cream, Vagifem) Pelvic floor weakness, multiparity, pelvic surgery Kegel exercises to strengthen pelvic floor No leakage when in supine position Bladder neck falls below pubic symphysis Vaginal Pessary Shortened urethra Possible surgery Bulking agents S/P RRP and TURP Artificial urinary sphincter, male urethral sling Artificial Sphincter Urge Incontinence Total Incontinence Symptoms Etiology Lab Findings Treatment Symptoms Uncontrolled loss of urine preceded by a strong, unexpected urge to void Indicative of detrusor overactivity Urine culture: UTI indications Anticholinergics: tolderadine, oxybutynin, solifenacin Involuntary loss of Anatomic abnormalities urine at all times and in all positions Unrelated to position of activity May be caused by inflammation, neurogenic disorder, urethral obstruction, detrusor instability Urodynamic evaluation: bladder and sphincter dysfunction Antispasmodics; Hyoscyamine Tricyclics: amitriptyline, imipramine Surgery Treatment Cysto: increased bladder length or bladder neck displacement Leak w/Coughing, sneezing, lifting, laughing, running Pessaries come in all shapes and sizes Bladder training Lab Findings Etiology Sp cte Sphincter deficiency due to surgery, nerve damage, cancer Lab Findings Treatment Surgical corrections External te a co condom do catheters Fistula between urinary tract and skin that bypassed sphincter Ectopic ureteral orifices, urethral diverticula, vesicovaginal 3 2/11/2014 Overflow Incontinence Nephrolithiasis – Urinary stone disease Symptoms Etiology Lab Findings Treatment Uncontrolled loss of urine due to chronic UTI Most common in men: BOO Intravesical pressure exceeds resistance of sphincter PE: BPH Behavior modification Urine dribbles out of distended bladder PVR: >300cc Urethral obstruction (Men prostate enlarged), urethral stricture or prostate cancer Surgical intervention: TURP/TUIP Neurogenic bladder: MS, DM, CVA Catheterize self Urine test for renal function Renal Stones • Basics • 90% of kidney stones are radio-opaque • A metabolic or environmental etiology can be found in >/= 97% of patients with stone disease • Most common stone is calcium oxylate ** • Most common metabolic cause of stones is hypercalciuria (high calcium in urine) ** • No pain no treatment • Symptomatic then surgical intervention: ESWL vs Perc vs basket Calcium Nephrolithiasis Symptoms Etiology Treatment Type Lab findings Treatment Colicky pain that comes on suddenly M:F 4:1 Stone analysis Sedentary lifestyle 1st- baseline 2nd- more more prone extensive Lab findings Watchful waiting depending on size <5mm should pass on own Hypercalciuria Increased Type I: Absorptive absortion in independent small intestine of Ca intake XR: radiopaque Ca ot get into Cannot to comfortable position Age: ge 30 30-40 0 yo Genetic factors U UA:micro coo or g gross oss hematuria Su g ca ESWL, Surgical: S , Ureteroscopic stone extraction Pain may refer to ipsilateral testis of labium Geographic: hot summer, high humidity pH: >7.5 struvite pH<5.0 uric acid or cystine I: decrease bowel absorption of Ca II: decrease Ca in diet III: inhibit Vit D synthesis Resorptive Hyperparathyroid XR:radiopaq If stone at UVJ, pt complaint of urinary frequency and urgency Diet and fluid intake: dehydration KUB/RUS won’t dx most stones Surgical resection of the adenoma Hypercalciuric Renal Renal tubules XR:radiopaq can’t reabsorb filtered Ca HCTZ UPJ, UVJ, iliac crest IVP/CT for location/hydro Hyperuricosur ic - renal Dietary excess of uric acid Purine dietary retrictions allopurinol Calcium Nephrolithiais Symptoms Etiology UpH >5.5 Other GU Stones Type Symptoms Etiology Lab findings Treatment Type Symptoms Etiology Lab findings Treatment Hyperoxalauria Renal Same as CaOx Intestinal disorder Chronic diarrhea, IBD, steatorrhea XR: Radiopaque Calcium supplement Uric Acid Hx of gout Composed of uric acid XR:radiolucnt UpH <5.5 Pot Citrate Allopurinol Cystine Smooth with ground glass appearance appea a ce XR:radiolucnt UpH<5.0 Citrate binds to calcium XR: Radiopaque Increase fluid Alkalinize u e >7.5 urine 5 Pot Citrate Struvite XR: Magnesium Radiopaque Commonly UpH: >7.0 seen in women with UTI Proteus, psuedomonas , providencia Hypercitrauria Renal Potassium citrate Can recur rapidly! Perc Neph Periop abx 4 2/11/2014 Imaging of Stone in GU Tract They come in all shapes and sizes! Hematuria Definition • 3 RBCs/HPF on two of three urinalysis • First morning specimen is best • One or more episodes of gross hematuria • One or more episodes of high-grade microscopic hematuria (>100 RBCs/ HPF) Hematuria False Positives Hematuria False Negatives • Myoglobinuria • High vitamin C intake • Hemoglobinuria • Presence of reducing substance • Povidone/iodine contamination • Drugs that may cause red urine: • Pyridium, phenytoin, ibuprofen, levodopa, methyldopa, nitrofurantoin, phenacetin, quinine, rifampin, sulfamethoxazole, chloroquine 5 2/11/2014 Hematuria: Differential Diagnosis Hematuria Work Up • Numonic – SHITTT! (Know) • Stones • Hemoglobinopathies • Infection • Trauma • Tumor • Tuberculosis • History/PE • BPH – Benign Prostatic Hypertrophy (Hyperplasia) • Imaging- US, IVP, CT, MRI (Gold Standard is CT) • Urinalysis • Urine culture: ALWAYS SEND URINE CULTURE! • 24 Urine for protein • CBC- blood loss vs infection • Chemistries- renal function, electrolyte, PT, PTT • Cystoscopy +/- RPG • Renal biopsy Hematuria Take Home Points Bladder Cancer- TCC and CIS • SH*T cubed (know) Clinical Findings Lab Test Treatment • Urine culture Hematuria UA: hematuria,pyuria Intravesical chemo: BCG • Imaging Irritative voiding symptoms US, CT, URI: detect defects in bladder Surgery: TURBT initial • Cystoscopy Palpation of tumor Cystourethroscopy and biopsy Radiotherapy Asymptomatic (painless) chemotherapy Painless hematuria is bladder cancer until proven otherwise! Bladder Cancer Renal Cell Carcinoma Clinical findings Lab Test Treatment Hematuria Adenocarinoma Surgery: radical nephrectomy primary tx Flank pain/abd mass UA: hematuria S&S of mets: cough, bone pain Erythrocytosis Systemic symptoms: fever, weight loss Anemia Chemotherapy: not very effective Hypercalcemia CT: most useful US: determine solid/cystic XR: chest and bone scan 6 2/11/2014 Renal Cell Carcinoma Wilm’s Tumor (WT) • Also called Nephroblastoma • First described by Max Wilms in 1889 • Surgery and radiation were mainstay of therapy in frist half of 20th century (1915) • Use U off actinomycin ti i ushered h d iin modern d era off chemotherapy • WT is most common GU tumor in children with incidence of 8:1,000,000 • More than 75% of time, age at diagnosis is <5yrs • Male=Female, but blacks>whites Clinical presentation of WT WT Staging: National Wilm’s Tumor Study • Healthy child with abdominal mass • I- confinded tumor, total resection • Hematuria found <25% and is usually microscopic only • II- outside capsule (bx,spill), total resection • Imaging is essential • Ultrasound – solid renal lesion, status of renal veins and IVC • CTCT excellent ll t evall off contralateral t l t l kidney, kid liliver and d gross lymphadenopathy, baseline eval of chest • III- incomplete resection, massive spill, + LN • IV- distant mets (hematogenous) • V- Bilateral tumors • Survival in stages I-III is >90% • Adjuvant chemotherapy with 2-3 drug treatment is used in all patients Wilm’s Tumor Prostate Cancer Clinical Findings Lab Test Treatment Most are asymptomatic PSA: 0-4 (normal range) Radical Prostatectomy Open vs Robotic Focal nodules or hardened areas on prostate p ostate e exam a Level of PSA is not necessarily diagnostic Radiation therapy: IGRT Brachytherapy Obstructive voiding pattern TRUS prostate w/biopsy Sample from apex, mid and base Cryotherapy – freezing of prostate Lymphedema XR: tumors ( CT and bone scan) Hormone ablation: ADT #1 Cancer of Men in the U.S.!! Do annual DRE and PSA starting age 50. 7 2/11/2014 Testicular Carcinoma- Primary Tumor Clinical findings Lab Test Treatment Rare disease: 19-35 yo AFP (alphafeta protein) Beta- HCG Surgery: radical orchidectomy/PLND 90-95% germ cell tumors US: mass intra/extra testicular Radiation therapy: seminomas low stage Seminoma: never produce AFP XR: chest, chest abdomen abdomen, pelvis Chemotherapy: seminomas high stage Most common right testicle CT: chest, abdomen, pelvis Painless nodule, heaviness in testicle S&S of mets: cough, back pain, lower extremity edema Cryptorchidism: Undescended Testicle Incidence of Cryptorchidism • “Hidden Testis” • One of most common human disorders • Failure of testis to descend into the scrotum • At birth • 3.4% full term infants • 30.3% premature infants (esp. low birth weight) • Testes may descent once babies gain weight and get older • No racial propensity • Associated with certain chromosomal abnormalities • At 1 year • 0.8% -1.5% • 75% full term and 95% premature UDT spontaneously descent by 1 yr • Most that descend do so within the first 3 months Incidence of Cryptorchidism Imaging of UDT • Cremasteric reflex is most active during the 2nd through • Ultrasound • Helpful if testis is in inguinal canal 7th years of life • Retractile testes are inadvertently diagnosed as UDT (most common misdiagnosis) • 3% % of p pts with UDT- one or both testes are absent • 10% bilateral UDT • CT and MRI • Useful in locating bilateral UDT • Expensive and difficult in young child • Radiation exposure • Reliability is better in older children • Accuracy of radiologic tests – 44% 8 2/11/2014 Complications of UDT Complications of UDT • Neoplasia • Orchiopexy is recommended between 1 and 1 ½ yrs • Torsion (very painful, twisting of testicle that cuts off blood supply) • Unknown whether this will deter subsequent cancer • Increased incidence due to abnormality of testis and its mesentery • Prevents ultrastructural changes • Greatest incidence post-pubertal (12-18yrs) when testis increase in • 20% of testicular tumors in pts with UDT develop in contralateral testis • In bilateral UDT, 15% chance of tumor development in opposite testis size • More than 50% will be found to have a tumor • Abdominal pain and empty hemiscrotum • Diagnosis should be considered in a man with abdominal pain and empty hemiscrotum Complications of UDT Treatment of Cryptorchidism • Hernia • 90% have hernia sacs • Indications for orchiopexy • Permanently corrects a visible defect • Prevent psychopathologic tendencies at school age • Make testis easily palpable • Enhance future fertility y • Infertility • Testicular maldescent retards production of spermatozoa • Fertility in bilateral UDT is poor • The highter and longer the testis is out of the scrotum, the greater the likelihood of seminiferous tubule damage • Men with unilateral UDT have lower sperm counts • Most patients with bilateral UDT exhibit normal androgenization • Indications for orchiectomy • Inability to successfully place the testis in the scrotum • Older post pubertal patients • Intersex conditions with a dysgenetic testis • Patient’s choice • Testis is grossly abnormal Take Home Message on UDT Phimosis/Paraphimosis Definition Considerations Treatment • Cryptorchidism is one of the most common human Phimosis Inability to retract foreskin over glans penis Can lead to venous congestion and tissue damage Infection Small hemostat passed into foreskin orifice to dilate it and deliver glans p penis, Circumcision Dorsal slit Paraphimosis Entrapment and inability of foreskin to be pulled back over the glans penis in uncircumcised males True emergency Can result in penile necrosis Manual reduction after 5 minutes of ice in exam glove Push glans penis under foreskin while holding foreskin in place Dorsal slit disorders • Cooler environment needed for viable mature spermatozoa • 75% full term and 95% premature UDT spontaneously descend by 1 yr, most within first 3 months • Orchiopexy is recommended between 1 and 1 ½ yrs • 67-92% success rate with orchiopexy, varying by location and length from scrotum 9 2/11/2014 Phimosis/Paraphimosis Hydrocele • Collection of serous fluid in scrotum in up to 1% of males • Usually asymptomatic and superior to testicles • Transilluminate – light shines through it • Most pediatric cases are congenital can be from trauma, orchitis hiti or epididymitis idid iti • Get CBC, UA and scrotal ultrasound • Usually no acute treatment needed • Rarely is surgery indicated Varicocele • Bulging/swelling of spermatic vein • “Bag of worms” • Cluster of varicose veins • More prominent on left •S Surgical i l iintervention t ti if painful i f l • Or possible infertility suspected BPH= Benign Prostatic Hyperplasia BPH – signs and symptoms • Benign growth of prostate that increases with age • Nocturia • Urgency/frequency • Stream stops and starts • Hesitancy • High PVR • Azotemia • Urinary retention • Enlarged prostate on DRE 10 2/11/2014 Work up for BPH International Prostate Symptom Score • PSA- prostate specific antigen (0-4) • DRE- digital rectal exam • PVR-bladder distention, post void residual (<200cc, >300cc cath) • Uroflow U fl • UA- rule out infection • UDS- urodynamic study (<15ml/s w/125cc voided- obstruction) • IPSS – mild 0-7, moderate 8-19, severe 20-35 Management and Treatment of BPH Treatment of BPH • Mild symptoms- watchful waiting • Alpha blockers- relax smooth muscle • Terozosin (Hytrin) • Doxazosin (Cardura) • Tamsulosin (Flomax) • Alfuzosin (Uroxatrol) ( ) • Silodosin (Rapaflo) • Moderate to severe symptoms • Medications- mainstay of therapy • Alpha blockers • 5 5-alpha a p a reductace educ ace inhibitors b os • MIT- minimally invasive therapy • TUNA • TUMT • Laser • Surgery • TURP- gold standard • TUIP • Prostatectomy- for larger glands • 5-alpha reductace inhibitors (5ARIs)- shrink prostate • Finasteride (Proscar) • Dutasteride (Avodart) • PDE5 Inibitors • Tadalafil (Cialis daily 5mg) Surgical Treatment of BPH Erectile Dysfunction (ED) • TURP: transurethral resection of prostate • 90% retrograde ejaculation • Higher risk bleeding • Consistent inability to maintain an erection with sufficient • TUIP: transurethral incision of prostate • Better from younger men • Pt with elevated bladder neck • Less morbidity • Prostatectomy • Reserved for those with large prostates • Have failed all other therapies rigidity to allow sexual intercourse • Causes • Medications-anticholinergics, narcotics, BP meds, antihistamines • Psychological- 10% (90% organic) • Vascular disease-CAD, HTN, DM • Drug abuse- ETOH, nicotine, opiates • Hormonal disease-pituatary, thyroid, adrenal gonadal • Neurologic disorder- MS, tumors, syphilis, parkinson’s • Iatrogenic-prostatectomy, vascular, back surgery • Trauma- disc and spinal cord injury • Treatment • Conservative vs Medications vs surgery 11 2/11/2014 Treatment of ED Treatment of ED • Conservative • Increase exercise • Quit smoking – most common cause of ED • Quit alcohol • Healthy y diet • Adequate sleep • Psychosexual counseling • Medications- increase blood flow • Oral – Sildinafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra, Staxyn) • Vasoactive therapy – direct injection of prostaglandin • Alprostadil urethral suppository • Understand the problem • Remove anxiety • Teach communication skills • Teach permission giving • Hormonal replacement- increase libido • Testosterone, DHEA • Devices • Vacuum erection device (VED) • Surgery • Penile prosthesis • Vascular reconstruction Questions? • A 68 yr old man has urgency, post void dribbling and nocturia. He is diagnosed with BPH. What is the preferred oral therapy? • A: Sildenafil • B: Ginsing g • C: Nifedipine • D: Clonidine • E: Doxazosin Questions? Question? • A 56 yr old man has just passed a calcium kidney stone. • Which of the following is considered to be the most Evaluation reveals hypercalciuria without hypercalcemia. Which of the following is the preferred therapy? important risk fact for urinary bladder cancer? • A: cyclamate ingestion • A: Parathyroidectomy • B: coffee consumption • B: High g p protein diet • C: acetaminophen p ingestion g • C: Oral administration of furosemide • D: cigarette smoking • D: Oral administration of hydrochorithiazide • E: strontium exposure • E. Oral administration of acetozolamide 12