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  3. Urology

Urology

Modified 18:11, 5 May 2017 by apavel | Page History
    Table of Contents
    1. 1. Bladder Symptoms
    2. 2. BPH
    3. 3. Prostate Specific Antigen (PSA)
    4. 4. Renal Colic
      1. 4.1. Information
      2. 4.2. Management
      3. 4.3. Prognosis
      4. 4.4. Recommendations for surgery
    5. 5. Voiding Problems

    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
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