Urology

    Bladder Symptoms

    Obstructive Symptoms Irritative Symptoms
    Hesitancy (problem starting) Urgency
    Diminished size/force of stream Frequency
    Stream Interruption (double voiding) Nocturia
    Urinary retention (incomplete emptying) Urge incontinence
    Post-void dribbling Dysuria
    Overflow incontinence  

    BPH

    • Obstructive bladder symptoms (see above)
    • Treatment:
      • Conservative
        • fluid restriction (avoid alcohol and caffeine)
        • Pelvic Floor Exercises
        • Bladder retraining - voiding schedule
      • Medications
        • Avoid certain medications (e.g. antihistamines, diuretics, decongestants, antidepressants)
        • alpha receptor antagonists [e.g. terazosin (Hytrin), dexazosin (Cardur), tamsulosin (Flomax), alfuzosin (Xatral)
          • Less Selective (more postural symptoms): Doxazosin, Terazosin
          • More Selective (less postural symptoms); Tamsulosin, Alfuzosin, silodosin
        • 5-alpha reducase inhibitor [e.g. finasterid (Proscar)]
          • Only for pts with demonstrated BPH
          • Reduces prostate growth by inhibiting enzyme conversion testosterone to DHT
        • Phytotherapy? (saw palmetto berry extract...unclear.. more studies needed)
      • Tests
        • Cr, BUN
        • Post-void residual by ultrasound
      • Surgery
        • TURP: transurethral resection of the prostate
          • Indications failed medical therapy, intractable urinary retention, compl. lead to renal problems.
          • Complications: impotence, incontinence, ejaculatory difficulties (retrograde ejaculation), decreased libido
        • TUIP: transurethral incision of the prostate - if prostate <30g
        • Stent

    Prostate Specific Antigen (PSA)

    • Protein produced by prostatic tissue
    • Screening: Do not screen.  NTT=1055 based on NEJM 2012; 366:981-90
    • Values
      • <4.0 ng/mL: normal, (take into account age and velocity)
      • 4-10 ng/mL: consider measuring free/total PSA
      • >10 ng/mL: high likelihood of prostate pathology
    • False positives with prostatitis, UTI, recent ejaculation, etc..

     

    Renal Colic

     

    Information

    • Symptoms

      • Severe renal "colic"

        • Constant flank pain -- capsular distention

        • Ureteral spasm - colic radiating from groin

      • Nausea+ vomiting

      • Urinary irritative symptoms (if near bladder orifice)

      • Hematuria - usually microscopic, sometimes gross

    • 10% by age 60, 50% dchance of recurrence in 5 years.

    • 90% radioopaque on KUB

    • Calcium Oxalate (~80%)

      • Calcium oxalate or calcium phosphate

      • Grey/brown/black

      • Radioopaque

      • Check for hypercalcemia

      • Prevention

    • Uric acid (~10%) -  radioluscent  (Acid urine pH < 5.5)

    • Struvite (~10%)  - urease organisms (ecoli etc..) split urea.  Alkaline urine (pH >7.5)

     

    • If it's calcium oxalate (80%)

    • High fluid >2L/day

    • Reduce animal protein intake (lowers urinary calcium, lowers pH, enhances citrate exretion)

    • Reduce sodium (lowers urine calcium)

    • Reduce oxalate (nuts, chocolate, teas, sphinach)

    • Reduce alcohol (causes hypercalciuria)

    • DO NOT REDUCE CALCIUM INTAKE (binds oxalate, helps clear it out)

     

    Management

    • Analgesia: narcotics (morphine)
    • Anti-emetics: Gravol
    • NSAIDS: Lowers intra-renal pressure -  must stop 48hrs before SWL
    • Antibiotics: if UTI sx
    • IV fluids: May make it worse
    • Medical Expulsive therapy: (Alpha-blockers help passage)
    • SURGERY:
      • Shockwave lithotrypsy >70% success
      • Ureteroscopy: >90% success
    • (Metabolic workup for recurrent frequent stones)

     

    Prognosis

    • Stones <5mm - 70% pass in 2 weeks.
    • Medical Expulsive therapy: alpha-blockers (tamsulosin, Flomax (C)) increase stone passage by 20-30%

     

    Recommendations for surgery

    • Need urgent management if:
      • Pain not controlled with analgesics
      • Fever or evidence of UTI
      • Solitary kidney or bilateral obstructing stones
      • Severe hematuria
      • Refractory vomiting
    • <1cm asymptomatic, non-osbtructing --> Conservative Management (observation)
      • Hydration, analgesia
      • Medical Expulsive Therapy
        • Alpha blocker such as tamsulosin
          OR
        • CCB such as nifedipine)
        • Glucocorticoids sometimes used to decrease swelling (controversial)
      • Urologic Referral Indicated if:
        • Urosepsis
        • AKI
        • Anuria
        • Refractory Pain
        • High risk (i.e. single kidney)
    • >1cm stone requires intervention
      • Shockwave Lithotrypsy (SWL)
        • <1.5 SWL alone
        • 1.5-2.5 SWL + ureteric stent
      • Ureteroscopy
        • If <2 cm
        • if patient preference or failed SWL
      • Percutaneous nephrolithotomy
        • >2.5cm or staghorn stones

     

    Voiding Problems

    • Urge incontinence (strong urge to urinate, leakage of urine before getting to bathroom)
      • First test is voiding diary 
    • Stress incontinence (leakage on incr abdominal pressure, such as laughing, sneezing, coughing)
    • Obstructive symptoms
      • Get post-void residual
    Tag page (Edit tags)
    • No tags
    Page statistics
    9915 view(s), 8 edit(s) and 7588 character(s)

    Comments

    You must login to post a comment.

    Attach file

    Attachments