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Lower Urinary Tract Symptoms & Incontinence
PRIMARY CARE UPDATE IN UROLOGY
Primary Care Update in Urology
Lower Urinary Tract Symptoms (LUTS)
Normal Bladder = 300 – 500 cc capacity, STORES at low pressure with appropriate
outlet resistance, EMPTIES by adequate bladder contraction without outlet
resistance.
LUTS occur due to problems with:
 STORAGE or ability of the bladder to hold urine
 EMPTYING or ability of the bladder to void
Male
Bladder
Female Bladder
3
Primary Care Update in Urology
Incontinence
Failure to Store
Urge
Overactive bladder
Decreased bladder
compliance
Stress
Intrinsic sphincter
deficiency
Pelvic floor laxity
Neuropathic sphincter
Acontractile bladder
Prostatic, urethral
obstruction
Dyssynergic sphincter
Overflow
Total
Failure to Empty
Neuropathic sphincter
Sphincterotomy
4
Primary Care Update in Urology
Abnormal Storage
Abnormal Emptying
OVERACTIVE Bladder
1.
Frequent voiding or small amounts with
compelling need to void(Urgency)
2.
If outlet resistance inadequate then urge +
stress urinary incontinence
NORMAL Bladder
1. Outlet obstruction (i.e. BPH, urethral
stricture) = RETENTION
UNDERACTIVE Bladder
1.
Retention if outlet resistance high
2.
Poor outlet resistance or bladder fills with
pressure > outlet resistance then overflow
incontinence
UNDERACTIVE Bladder
1. Hypotonic bladder = RETENTION
5
Primary Care Update in Urology
Evaluation of LUTS
History: Qualitate the voiding by frequency day & night, urgency vs
stress incontinence, hesitancy, straining to void, feeling of bladder being
empty after void. In male IPSS form.
Physical Exam: Assess for bladder distension, objective SUI, descent of
anterior vaginal wall with straining, condition of vaginal mucosa,
presence of cystocele/rectocele. Rectal exam to assess prostate size and
consistency.
Voiding Diary: Includes amount & type of fluid consumed, times of
voiding and any associated bladder symptoms, record incontinence in
relation to void times.
Office assessment: Urinalysis, Urine C&S, U/S of Bladder for PVR
Referral for: Urodynamics (UDS) + Cystoscopy
6
Primary Care Update in Urology
Treatment Options
Urge Incontinence: Determine if patient wants treatment.
1. Behavior Modification: Q2H voiding, reduced fluid intake, avoid
bladder irritants, Kegel maneuvers
2. Anticholinergics: Reduce bladder contraction pressure. Side
effects = retention, dry mouth/eyes, constipation, tachycardia,
drowsiness, confusion. Contraindicated in acute angle glaucoma.
Overflow Incontinence: Assess for obstruction
TURP / urethrolysis
1. Clean intermittent catheterization (CIC)
Stress Urinary Incontinence: Kegel maneuvers, alpha-agonists (e.g.
pseudoephedrine) which increase BN tone, pessary
Referral for surgical management of ISD vs. anatomic SUI
7
Primary Care Update in Urology
Treatment Options (continued)
Mixed Incontinence: Behavior modification + meds
Total Incontinence: Condom catheter or artificial sphincter
8
Erectile Dysfunction & Cardiometabolic Risk
PRIMARY CARE UPDATE IN UROLOGY
Primary Care Update in Urology
Erectile Dysfunction (ED) & Cardiometabolic Risk
ED is the inability to reach or maintain erection sufficient for
satisfactory sexual performance.
Primary vascular disorder in men > 30 yrs old therefore potent predictor
of cardiovascular disease (CVD).
ED is associated with BP, lipidemia, DM, & depression.
ED is independent predictor of CV morbidity & mortality in DM patients
with silent CAD.
ED precedes CVD by 2 to 5 years.
ED predicts CVD in non-DM middle aged
men.
10
Primary Care Update in Urology
Erectile Dysfunction & Coronary Artery Disease
 May be different manifestations of the same underlying blunted
endothelial dependent vasodilation response.
 Therefore, impaired vasodilation of the penile artery may be the first
vascular “stress test” of a more diffuse vascular disease process.
 Framingham risk score (FRS) suggests ED is a potent predictor of
all-cause death and the composite of CVD, myocardial infarction,
stroke & heart disease.*
Patients with ED should be evaluated for CVD
risk factors and aggressively treated for
hypertension, hyperlipidemia, diabetes & obesity.
11
Primary Care Update in Urology
Physiology of Normal Erection
Nitric oxide is neurotransmitter that activates endothelial
guanylyl cyclase and raises intracellular cyclic GMP which
opens K+ channels resulting in relaxation of cavernosal
arteries and filling of venous sinusoids. This causes
constriction of subtunical venous plexus thereby reducing
venous outflow = erection.
12
Primary Care Update in Urology
ED Categories
Disorders
Problem
Psychogenic
Performance anxiety
Depression
Loss of libido, Overinhibition,
Impaired NO release
Neurogenic
Stroke, Spinal cord injury,
Diabetic retinopathy
Hormonal
Hypogonadism,
Hyperprolactinoma
Inadequate nitric oxide (NO)
Release
Atherosclerosis, hypertension
Impaired arterial or venous flow
Antihypertensives,
Antidepressants, Alcohol,
Cigarette use
Central suppression,
Vascular insufficiency
Vasculogenic (arterial or
venous)
Medication Induced
Lack of nerve impulse, or
Interrupted transmission
13
Primary Care Update in Urology
Treatment of ED
 Lifestyle changes – quit smoking, loose weight, exercise regularly
 Psychotherapy – for patients with performance anxiety & overinhibition.
Treat depression
 Oral Therapy – PDE5 Inhibitors (sildenafil, vardenafil, tadalafil)
Testosterone
 Vacuum Erection Devices
Referral to Urology for:
 Intracavernosal Injection Therapy – papaverine, phentolamine, prostaglandin
E2 (alprostadil)
 Intraurethral Injection Therapy – prostaglandin E2 (alprostadil)
 Penile Erectile Prosthesis
14
Prostate Cancer Overview
PRIMARY CARE UPDATE IN UROLOGY
Primary Care Update in Urology
•
•
2nd most common cause of cancer deaths (11%) in males, behind lung and bronchus (28%)
High risk groups include men with a first-degree family member who has or had
prostate
cancer, African American men
Prostate cancer diagnosis:
Symptoms
- early – often none
- advanced - bone pain and constitutional symptoms (weakness and weight loss)
Rectal examination - prostate nodule (hard), asymmetry; portion of gland is not compressible
(more firm)
Prostate specific antigen (PSA)
- prostate specific , but not prostate cancer specific
Benign conditionsbenign prostatic hyperplasia (BPH),
urinary tract infection (cystitis and prostatitis)
urethral instrumentation (bladder catheterization and cystoscopy), urinary
retention and recent ejaculation
Prostate Cancer - LOW specificity of PSA testing for prostate cancer 15% of patients with a normal PSA level have prostate cancer
16
Primary Care Update in Urology
Ways to make elevated PSA more sensitive /specific for Ca
•
Age-Specific reference range for serum PSA
•
PSA Velocity - How quickly does their PSA level go up?
•
PSA Density - How does the PSA value correlate with the size of their prostate?
•
Percent Free PSA - What is the ratio of free/total PSA? > or < 15%
AUA Recommendations for PSA Screening in Prostate Cancer Detection- 2013
•
Focus on men ages 55-69
•
Not recommended for average-risk *men 40-54, after age 70, or for men with
average life expectancy of less than 10-15
•
Not recommended for men younger than 40
•
Should include a thorough discussion of risks and benefits of screening between
patient and physician
* 40- 54 yrs old - Men at high risk - family history or African-American race should
be considered for PSA testing
US Preventive Services Task Force (USPSTF) - Do not screen for prostate cancer in men
75 years or older
17
Primary Care Update in Urology
US Preventive Services Task Force (USPSTF)
PSA Testing Recommendations
Draft Form, Oct 7, 2011- Ann Int Med
• recommends against prostate-specific antigen (PSA)-based
screening for prostate cancer. This is a GRADE D*
recommendation.
• * Moderate or high uncertainty that the service has no net benefit or
that the harms outweigh benefits
18
Primary Care Update in Urology
IMPORTANT FACTS TO CONSIDER ABOUT USPSTF
PSA SCREENING RECOMMENDATIONS:
•
•
•
•
No Urology, Radiation or Medical oncology representative on Task
Force
In 1988, 19.2% of patients diagnosed with prostatic cancer already
had locally advanced disease.
In 1998, only 4.4% had locally advanced cancer at diagnosis.
In PSA era, diagnosis of advanced CaP has decreased > 75%
19
Primary Care Update in Urology
IMPORTANT FACTS TO CONSIDER ABOUT USPSTF
PSA SCREENING RECOMMENDATIONS:
•
Prostate Cancer death rates have fallen >40% from 1993-2006
(Göteborg CaP screening study)
•
Statistical models suggest that 45-70% of this decrease is due to
screening
•
Globally CaP has decreased in countries where screening is
practiced; has stayed stable or increased in countries that don’t
screen
20
Primary Care Update in Urology
PLCO Screening Study
Emphasized by USPSTF
• USA - 76,000 men– No Difference
FLAWED!
– Extensive PSA testing before study entry
– Removed many pts with life-threatening CaP from study
population
– Extensive screening of controls during study
– Use of outdated PSA cut-off (4 ng/ml)
– Failure of those in screening arm with abnormal results to
undergo prompt biopsy
– Premature reporting of mortality results
– Shorter Follow-up (7 yrs)
21
Primary Care Update in Urology
European Randomized Study of Screening for Prostate
Cancer (ERSPC)
•
Europe- 182,000 men randomized screening trial reduced prostate
cancer deaths by 20% with 41% reduction in metastatic disease
(NEJM, March 2009)
•
ERSPC- Follow-up to 11 years – continued reduction in risk of death
from CaP (29% compared to non-screened) (NEJM, March 2011)
22
Primary Care Update in Urology
OTHER IMPORTANT FACTS TO CONSIDER ABOUT PSA
SCREENING RECOMMENDATIONS:
• CaP arises and progresses silently
• Symptoms often reflect incurable state
• Every man has right to make decisions and self
determination
• PSA test is not perfect BUT it currently is the best we
have to pick up potentially lethal CaP
• Use of PSA velocity, % free PSA, PSA/Density helpful
• Finding a new prostate cancer test- top research priority
23
Primary Care Update in Urology
Diagnosis of Prostate Cancer
Transrectal ultrasound-guided prostate biopsy
Clinical Staging of Prostate Cancer
•
•
•
•
•
•
Digital rectal exam
Gleason grade
PSA value
Bone scan, - if PSA > 20 ng/ml
Pelvic CT or endorectal MRI – if strong concern of advanced disease
Pelvic lymphadenectomy – if strong evidence of locally advanced pelvic
disease and adenopathy
24
Primary Care Update in Urology
TREATMENT OPTIONS
•
•
•
•
•
Active Surveillance – watch closely with repeat PSA and prostate biopsies at
regular intervals
Radical Prostatectomy – potentially curative – open/laparoscopic/robotic
Radiotherapy – potentially curative - external beam/brachytherapy (seeds) +/adjunctive androgen suppression
Cryotherapy – not considered first line of treatment
High Intensity Focused Ultrasound – not considered firstl ine treatment
Rising PSA after curative therapy is most likely due to persistent or
recurrent prostate cancer
•
Androgen deprivation therapy (ADT) for advanced or metastatic prostate cancer that is
sensitive to androgen-suppression
•
Chemotherapy (docetaxel-based) and immunotherapy (sipuleucel-T) for advanced
prostate cancer that is not sensitive to androgen-suppression (“hormone resistant”)
25
Primary Care Update in Urology
Prostate Cancer Prevention
•
•
•
•
Selenium, Vitamin E, Cox-2 inhibitors – No level 1 evidence to support
Sawpalmetto – No level 1 evidence to support
Whole tomatoes, pomegranates - No level 1 evidence to support
5 alpha-reductase inhibitors (5-ARI’s) -- Dutasteride and Finasteride
Yes – reduces prevalence but :
Prostate Cancer Prevention Trial (PCPT)
• randomized 19,000 men into placebo versus finasteride
• followed for seven years
• 24.8% reduction in prevalence of prostate cancer in the finasteride group
compared to the placebo group
• prostate tumors of higher Gleason grade (7, 8, 9, or 10) were more
common in the finasteride group
26
Primary Care Update in Urology
Prostate Cancer Prevention (continued):
Reduction by Dutasteride of Prostate Cancer Events Study (REDUCE)
• 22.8% reduction in prostate cancer in the dutasteride group compared
to placebo
• no increase in higher Gleason grade tumors
• cardiac failure seen more often in the dutasteride group compared to
the placebo group
• Before prescribing 5-ARI’s to prevent prostate cancer, and in patients taking
5-ARI’s for lower urinary tract symptoms, discuss the risks and benefits with
the patient; communication between primary care physicians and their
Urology colleagues on the use of 5-ARIs is essential
27
Interstitial Cystitis & Bladder Pain Syndrome
PRIMARY CARE UPDATE IN UROLOGY
Primary Care Update in Urology
Interstitial Cystitis / Bladder Pain Syndrome (BPS)
Symptoms: Frequency, urgency + pelvic pain & incontinence. Tends to be
slowly progressive with insidious onset. Dyspareunia flares common.
Often diagnosed as ‘recurrent UTI’, but by definition C&S negative
Pathophysiology: Upregulated stretch (urgency) and pain fibers of the bladder.
Barrier between urine metabolites and bladder interstitium abnormal.
Mucous layer (normally highly anionic) on apical membrane of umbrella
cells of transitional epithelium attracts H2O.
K+ > 8 mEq/L will depolarize nerve & muscle cells. Prolonged
depolarization results in cell death. Urine K+ levels = 30 – 120 mEq/L.
So if mucosal barrier abnormal K+ from urine is absorbed and is very
irritating to bladder interstitium.
29
Primary Care Update in Urology
DIAGNOSIS OF IC / BPS
Potassium Sensitivity Test (PST): 80% of patients tested positive after injury to
mucosal layer with protamine in study of normal population, supportive of epithelial
dysfunction & absorption of K+ into bladder interstitium causing BPS symptoms.
Evaluation of IC Patient:
Loss of Umbrella Cells
Urinalysis
Urine C&S – if negative then treat
Normal Umbrella Cells
30
Primary Care Update in Urology
TREATMENT of BPS
Principles of Treatment
1. Correct epithelial dysfunction – Heparin intravesically (40,000 U
heparin + 200 mg lidocaine + 2 ml of 8.4% NaHCO3) 2 – 3 treatments
in 1 week instilled and left for 30 minutes. Can continue several
weeks if necessary.
Heparinoid – Pentosan polysulfate (PPS) 100mg TID or 200mg BID
2. Inhibit neural hyperactivity – Amitriptyline 25 – 50 mg @ HS,
anticholinergics & antmuscarinics are less effective.
3. Control allergies (histamine flares, IC symptoms) – Hydroxyzine 25
mg increased to 50 – 75 mg @ HS for several weeks.
4. Advise patient to avoid bladder irritants and timed voiding.
31
Urinary Tract Infections
PRIMARY CARE UPDATE IN UROLOGY
Primary Care Update in Urology
Estimated:
150 million UTI’s worldwide / year with $6 billion annual healthcare
cost
More common in females than males
Of nosocomial infections UTI accounts for 40% - related to indwelling
Foley catheters
Causative organisms associated with common UTIs
33
Primary Care Update in Urology
Source of Bacteria
Organisms
Bowel
Perineum
Vagina
E coli – 80% of UTI’s
Klebsiella; Enterobacter
Proteus
Pseudomonas
Staphylococcus saprophyticus
(5 – 15%)
Enterococcus
Candida
Adenovirus type 11
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Primary Care Update in Urology
Symptoms:
 Lower Urinary Tract - Bacteria adhere to urothelial cells
and establish an inflammatory response in the
subepithelial and muscle layers of the bladder.
The inflammatory response gives rise to frequency, urgency, dysuria due to the
inflammation of the detrusor muscle. There may also be hematuria, foul odor to the
urine, & suprapubic pain.
Upper Urinary Tract - The bladder edema caused by cystitis
distorts the normally anti-reflux anatomy of the intra-mural
ureter allowing reflux of infected urine from the bladder to the
kidney.
The bacteria adhere to the upper UT urothelium and cause inflammation of the
renal parenchyma. Swelling of the kidney stretches the renal capsule which
has pain sensors
& causes flank pain, nausea, and fever if bacteria
and endotoxins enter the vascular system.
35
Primary Care Update in Urology
What Evaluation is Suggestive vs Diagnostic of UTI?
Urine Dipstick
+ Leukocyte esterase (64-90%
sensitivity)
Urine Microscopy
Urine
Culture
+ Nitrite (50% sensitivity)
+ Blood
WBC > 10/hpf (95% sensitive)
RBC
Bacteria (>98% sensitive)
Epithelial cells
Organism
Colony count > 100,000
36
Primary Care Update in Urology
UROPATHOGENS
Common Causative pathogens in Adult UTIs
E. Coli (80% of outpatient UTIs)
Klebsiella; Enterobacter
Proteus
Pseudomonas
Staphylococcus saprophyticus (5 – 15%)
Enterococcus
Candida
Adenovirus type 11
Normal perineal flora:
Lactobacillus
Corynebacteria
Staphylococcus
Streptococcus
Anaerobes
Other pathogens that mimic UTIs
Herpes genitalis (HSV)
Urethritis
N. Gonorrhoeae
Chlamydia
Trichomonas
Vaginitis
Prostatitis
Nephrolithiasis
Trauma
GU tuberculosis
GU neoplasm
Intra-abdominal abscess
Sepsis – source other than GU system
37
Primary Care Update in Urology
COMMON ANTIMICROBIALS FOR UTIS
B-lactam: PCN,
Cephalosporin
Inhibits bacterial cell wall synthesis
Aminoglycoside
Inhibits ribosome protein synthesis
Quinolones
Inhibits bacterial DNA gyrase
Nitrofurantoin
Inhibits several bacterial enzyme systems
TMP-SMX
Antagonism of folate metabolism
Vancomycin
Inhibits cell wall synthesis
38
Primary Care Update in Urology
Antibiotic Treatment Protocols
 Uncomplicated UTIs
3 days = 7 days TMP/SMX is 95% effective. Resistance to TMP/SMX implies resistant
to Ampicillin, Cephalosporin & Tetracycline.
 Other uncomplicated UTIs
7 – 10 days course for sxs > 7 days, DM pts, pregnancy, age > 65, hx of pyelo or hx of
resistant organism.
 Complicated UTI (pyelonephritis) – after C&S obtained start empiric tx with Amp +
aminoglycoside or Vancomycin. Adjust antibiotic according to C&S results. Blood
C&S positive in 20-40%. Treat for at least 14 days.
 Additional treatment information for UTI’s
Post-menopausal women prone to UTIs because reduced hormone effect on urothelium.
Treat with topical Premarin cream.
For uncomplicated UTIs in women > 4x per year consider low dose suppressive therapy
or Rx for prn use by patient.
For uncomplicated UTIs related to intercourse use antibiotic with intercourse and 12
hours later.
Bowel management and regular voiding regime may also be very helpful to reduce
recurrent infections.
39
Primary Care Update in Urology
Indications for Urology Consult & Further Radiologic
Investigation
History of stones
Ureteral Obstruction
Papillary Necrosis
Poor response to antimicrobial tx
Neuropathic bladder
History of GU surgery
Polycystic kidney
Unusual infecting organism
Diabetes mellitus
40
Hematuria
PRIMARY CARE UPDATE IN UROLOGY
Primary Care Update in Urology
Hematuria
 Microhematuria: detected on dipstick or microscopy; >3 RBC/hpf Dipstick has
95% sensitivity & 75% specificity – confirm with Micro False positive dipstick
from free Hbg, myoglobin, antiseptic solutions (povidone-iodine)
 Gross hematuria: visible to the patient. Patient can confuse bleeding from
rectum or vagina therefore careful history important.
Prevalence = 1 – 20%
Risk Factors:
Age > 40 years
Male gender
Hx cigarette smoking
Hx of pelvic radiation
Hx chemical exposure (cyclophosphamide, benzenes)
Irritative voiding symptoms (freq, urge, dysuria)
Prior urologic disease or treatment
42
Primary Care Update in Urology
Hematuria
ETIOLOGY – can occur anywhere along the urinary tract
 Glomerular- usually RBC + proteinuria (>1000 mg/24hrs)
Red cell casts & dysmorphic RBC suggestive of glomerular
origin.
Common causes = IgA nephropathy (Berger’s disease), thin
glomerular basement membrane disease, hereditary nephritis
(Alport’s disease)
RBCs
Dysmorphic
RBCs
 Non-glomerular
RBC
Casts
Upper Tract (kidney & ureter)
Lower Tract (bladder, prostate & urethra)
43
Primary Care Update in Urology
Common Causes of Non-Glomerular Hematuria
Upper Urinary Tract
Urolithiasis
Pyelonephritis
Renal cell cancer
Transitional cell carcinoma
Urinary obstruction
Benign hematuria
Lower Urinary Tract
Bacterial cystitis (UTI)
Benign prostatic hyperplasia
Strenuous exercise (“runner’s
hematuria”)
Transitional cell carcinoma
Spurious hematuria (e.g. menses)
Instrumentation
Benign hematuria
44
Primary Care Update in Urology
Evaluation of Hematuria
History: patient symptoms, smoking hx, occupational exposure, hx of pelvic
radiation, chemotherapy (cyclophosphamide)
Physical exam: BP, edema, cardiac arrhythmias, flank tenderness, menopausal
atrophic changes, vaginal exam, rectal exam & assess prostate size
& consistency
Gross hematuria
C&S, Cytology
Refer to Urology for
CT Urogram
Cystoscopy + anesthesia for
biopsy or ureteroscopy
Microhematuria
C&S, Cytology
U/S kidneys & bladder
+ CT Urogram if U/S abnormal
Cystoscopy if any of above
abnormal
45
Geriatric Urology: Demographics and Theories and Physiology of
Aging
PRIMARY CARE UPDATE IN UROLOGY
Primary Care Update in Urology
• Definition of Geriatrics: the study and clinical care of older adults;
traditionally, this was age 65 coinciding with the onset of Medicare benefits;
as people live longer, a more accurate description of the geriatric age group
is older than 70 or 75 years
• Increasing size of the geriatric population in the United States with 13% of
the population over 65 now; in 2030, this number will increase to 20%
• In the United States, the age group over 85 is growing the fastest; this is not
true in less developed countries where longevity is cut short by disease
• Human aging theory includes (1) evolution, an impairment in organ function
due to multiple mutations over time, (2) physiology, due to errors in DNA
sequencing and alterations in cellular function, and (3) modulation of the
immune system
47
Primary Care Update in Urology
Physiology of Aging
Decline in organ system function:
• Kidney - a decrease in renal blood flow, renal mass (25%), creatinine
clearance (10 ml/min/decade), urine concentrating ability and
renin/aldosterone production; serum creatinine may not accurately measure
renal function in frail elderly patients
• Bladder - a decrease in compliance (increase in collagen deposition),
contractility, volume, and sensation (changes in urothelial neurotransmitter
production/function)
• Prostate - stromal and glandular hyperplasia (BPH); prostatitis and prostate
cancer
48
Primary Care Update in Urology
Physiology of Aging (continued)
• Penis - changes in microvasculature and large blood vessels, and in erectile
tissue of corpus cavernosum (resulting in erectile dysfunction)
• Testis - a decrease in number and function of seminiferous tubules (testes
are smaller and softer), and Leydig cell response to gonadotropins (fall in
serum testosterone); if malignancy occurs, it is most commonly lymphoma
• Frailty - a clinical entity associated with (1) a decrease in functional reserve,
(2) comorbidities and (3) an impaired response to stress
49
Primary Care Update in Urology
Common Clinical Conditions - Urinary Tract Infection (UTI)
• Acute UTI - lethargy, anorexia and confusion are presenting symptoms; treat
with antibiotics based on urine culture and susceptibility results; check for
drug interactions and make dose adjustments for reduced kidney and liver
function
• Asymptomatic bacteriuria - in postmenopausal women (20%) and elderly
men (5-10%); no treatment required in the absence of symptoms
• E. coli, and Enterococcus and Enterobacter species are the most common
pathogens; with recurrent infection by multiple different bacteria, suspect
enterovesical fistula
50
Primary Care Update in Urology
Urinary Tract Infection (continued)
Prevention of UTI:
• In postmenopausal women, use of topical (vaginal) estrogen acidifies the
vaginal fluid leading to growth of natural host defense bacteria (Lactobacillus)
• Chemicals in cranberry supplements prevent bacteria from attaching to the
urothelium
• With retention of urine, choose clean intermittent catheterization over an
indwelling catheter to lessen the likelihood of infection, falls, and urethral and
bladder neck erosion
51
Primary Care Update in Urology
Common Clinical Conditions – Hematuria
American Urological Association guidelines define microhematuria as the
presence of greater than 3 red blood cells per high power field on at least 2
separate urine specimens
Evaluation:
• History - duration and frequency of bleeding, and associated pain (dysuria,
back and flank pain); risk factors for underlying pathology are smoking,
exposure to chemicals and analgesic abuse
• Exclude malignancy (bladder, kidney, ureteral), urinary stones and UTI with
(1) urine culture, (2) urine cytology, (3) cystoscopy and (4) CT scan of the
abdomen and pelvis without and with intravenous contrast; in patients with
renal insufficiency, avoid use of intravenous contrast by using renal
ultrasound and cystoscopy with retrograde pyelograms to evaluate the renal
parenchyma, ureters and bladder
52
Primary Care Update in Urology
Hematuria (continued)
• Evaluate microhematuria in patients taking anticoagulant medication as 1520% will have underlying urinary tract pathology
• Persistent microhematuria with a negative evaluation for structural
pathology, and coexisting hypertension and proteinuria, requires referral to a
nephrologist to exclude medical renal disease
53
Primary Care Update in Urology
Common Clinical Conditions – Nocturia
•
Nocturia, defined as waking from sleep to void, is associated with increased mortality and
may be considered a marker of overall health
•
Nocturia is associated with an increased risk of accidental falls
•
Nocturia is a bladder symptom (overactive bladder) and is related to other conditions such
as BPH, obstructive sleep apnea and congestive heart failure
•
Treatment of nocturia requires identification of causative conditions; in more than 50% of
patients, nocturia is due to more than one cause and multiple treatments or
multicomponent therapy is more effective than focusing on a single intervention – this
multicomponent framework lends itself well to geriatric medicine
Multicomponent therapy for nocturia:
• Behavior modification - change fluid intake and sleep patterns
• Treat peripheral edema
• Medication - bladder relaxant and alpha-blocker
54