Pitfalls of Urology for Undergraduate studies at Taylor University - PowerPoint PPT Presentation

David A. Anderson, MD ■ Born in Sioux City, Iowa Pitfalls of Urology for ■ Undergraduate studies at Taylor University ■ Medical School at University of Iowa College of the Gatekeeper Medicine ■ Internship and Residency at University of Iowa Hospitals and Clinics What are they and how to avoid them ■ Joined Ferrell Duncan Clinic, Springfield MO in 2005 David A. Anderson, MD ■ Interests include Robotics, Minimally invasive surgery Ferrell Duncan Clinic, 2016 and treatments of Incontinence

Objectives Anatomic Approach to Urologic Pathology ■ Bladder ■ Hopefully you will be able to… ■ Kidney ■ Renal Cell/Urothelial Cell ■ Urothelial Malignancies ■ Identify common clinical urologic presentations Tumors ■ Cystitis ■ Establish a quick differential diagnosis ■ Nephrolithiasis ■ Bladder Stones ■ Develop a diagnostic plan and execute treatment or ■ Congenital obstructions/ ■ Interstitial Cystitis refferal Hydronephrosis ■ Asymptomatic Bacteruria ■ Pyelonephritis ■ Hopefully you will not… ■ Incontinence ■ Renal Cyst ■ Stress ■ Be offended by my sense of humor ■ Urge ■ Be grossed out by pictures of scrotums ■ Overflow ■ Fall asleep out of complete boredom Clinical Approach to common Urologic Anatomic Approach to Urologic Pathology pathology ■ Prostate ■ Testicle ■ Hematuria ■ Definition, workup, common findings ■ Prostate Cancer ■ Testicular Cancer ■ Testicular Torsion ■ Elevated PSA ■ BPH ■ Epididymitis/Orchitis ■ Current recommendations, workup and causes ■ Prostatitis ■ Orchalgia ■ Flank Pain ■ Penis ■ Spermatocele ■ Differential dx, work up, referral ■ Penile Cancer ■ Hydrocele ■ Recurrent UTI’s ■ Penile Trauma ■ Varicocele ■ Causes, work up, treatment options ■ Phimosis/Paraphimosis ■ Undescended Testicle ■ Pelvic Pain ■ Differential dx, work up and treatment options

Kidney Kidney ■ Renal Cell Carcinoma ■ About 36,000 new cases each year in the U.S. ■ Results in about 12,500 deaths per year ■ Peak incidence is in 50-70 year olds ■ More common in men by 2:1 ■ Smoking accounts for 20-30% of cases ■ Obesity is a risk factor ■ Genetic factors identified for a minority of cases Kidney Kidney ■ Signs and Symptoms ■ Renal Cell Cancer Treatment ■ Hematuria (40-60%) ■ Surgery in cases without distant spread ■ Flank pain (30-40%) ■ Laparoscopic vs. Open Radical Nephrectomy ■ Weight loss (33%) ■ Robotic vs. Open Partial nephrectomy ( Tumors <4 cm) ■ Anemia (33%) ■ Radiation therapy ■ Palpable mass (25%) ■ Not very effective, almost no role ■ Chemotherapy ■ Diagnostic Studies ■ Not very effective ■ CT Ab/Pelvis w/ contrast ■ Immunotherapy ■ MRI ■ Not very effective, shown to add 2-4 months avg life expectancy ■ U/S

Kidney Kidney ■ Nephrolithiasis ■ Kidney stones ■ May detach and lodge in ■ Requires “supersaturation” of urine with an insoluble the ureter material such as calcium oxalate or cysteine ■ Acute pain syndrome ■ More likely if... ■ Hydronephrosis due to complete occlusion ■ Urine flow is low (water conservation) ■ May grow to large to pass ■ Mineral (esp. calcium salts) production is high & fill renal pelvis ■ Urine mineral concentration is high ■ “Staghorn calculi” ■ Idiopathic (hereditary) hypercalciuria ■ Deficit of mineral dissolvers such as Citrate Kidney Kidney ■ Clinical Presentation of Stones ■ Treatment options for Stones ■ PAIN!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ■ Ureteroscopy ■ Flank to lower quadrant as the stone passes ■ Using a scope to extract stone either with a basket or with a laser ■ Colicky in nature, usually 12/10 pain ■ Only risk in ureteral injury ■ Pain that narcotics wont help ■ Lithotripsy ■ Nausea and Vomiting ■ Very effective (95%) with only sedation ■ Hematuria ■ May cause renal damage ■ Urgency and frequency if stone is distal ■ Percutaneous Nephrolithotripsy ■ Testicular pain, pelvic pain ■ Directly into kidney, reserved for large stones

Kidney ■ Acute Pyelonephritis ■ Infection of upper urinary tract associated with fever, flank pain, pyuria, possible sepsis ■ Requires antibiotic therapy usually requires hospitalization and may need surgical intervention ■ Relieve obstruction with either stent or removal of stone ■ Xanthogranulomatous pyelonephritis is a chronic form where nephrectomy is required ■ Antibiotic treatment usually requires flouroquinolones, cephalosporins, or aminoglycosides (gent) Bladder Bladder ■ Urothelial Carcinoma (Transistional Cell Ca) ■ 60,000 new cases per year in the U.S. ■ 12,700 deaths per year ■ Males outnumber women by nearly 3:1 ■ 60-75% of cases are due to smoking or exposure to industrial dyes or solvents ■ Squamous Cell Carcinoma ■ Much less common ■ Usually found in patients who are chronically catheterized

Bladder Bladder ■ Signs and Symptoms ■ Diagnosis ■ Hematuria on UA leads to ■ Hematuria either IVP or CT Ab/ ■ Often gross but may be microscopic Pelvis and Cystoscopy ■ Presenting symptom in ■ Transurethral Resection 85-90% may be curative depending ■ Irritative voiding on stage symptoms ■ Most (50-80%) bladder cancers will be superficial at diagnosis: ■ Pain, masses with ■ CIS, Ta, T1 advanced disease ■ Advanced disease: Cystectomy vs Chemo/ XRT Bladder Bladder ■ UTI ■ UTI Signs and Symptoms ■ “ Irritative voiding symptoms ” ■ Simple/Uncomplicated UTI ■ Urinary frequency, urgency, pain (dysuria) ■ Cystitis in female, no other factors ■ Hematuria (may be microscopic) ■ Lower urinary tract involved, no fever, local symptoms ■ Fever: most common in children ■ Complicated UTI ■ Pyelonephritis ■ Cystitis in Male, pyelonephritis, catheterized patients, immunocompromised patients, or other factors ■ Fever, nausea, vomiting, flank pain ■ Upper tract involvement, instrumentation, catheters, ■ UA neurogenic bladders ■ Presence of WBC and Bacteria on UA, Nitrite +, Leukocyte esterase +, CULTURE

Bladder Bladder ■ UTI Diagnosis ■ Asymptomatic Bacteruria ■ UA ■ Common in the elderly ■ + WBC, +/- RBC ■ General recommendation is to not treat unless ■ +Nitrite patient becomes symptomatic ■ +Leukocyte esterase ■ + Bacteria ■ Fever, constitutional symptoms, dysuria, irritative ■ Culture symptoms ■ >100,000 CFU/HPF of ■ Also common in pregnancy bacteria ■ Usually treated to avoid pyelonephritis ■ Dipstick + Urine is ■ Also associated with premature labor correct 20% of the time!! Bladder Bladder ■ Urinary Incontinence ■ Treatment ■ Uncomplicated UTI ■ Stress Incontinence ■ 3-5 days of TMP/SMZ ■ Intrinsic urethral sphincter deficiency from age, ■ Hydration, AZO hysterectomy and multiple vaginal deliveries ■ Complicated UTI ■ Urge incontinence ■ 10-14 days of TMP/SMZ or Flouroquinolone ■ Overactivity of M2 and M3 receptors in the bladder ■ May need cephalosporin or augmentin causing an increase in contraction of detrusor ■ Change catheter or stent ■ Can be cause by detrusor dysfunction from MS, diabetes or ■ Pyelonephritis sacral nerve injury ■ 14-21 days of flouroquinolone ■ Most commonly idiopathic but must rule out infection and ■ May need IV abx w/ or w/o hospitalization intravesical lesions

Bladder ■ Urge incontinence treatments ■ Behavior modification (“bladder training”) ■ Void every 1-2 hours ■ Gradually lengthen time between voids ■ Eliminate irritants like smoking, caffeine, and acidic foods ■ Anticholinergic (antimuscarinic) drugs ■ Oxybutynin (Ditropan) Detrol LA, Vesicare, Enablex, Toviaz, Gelnique, Sanctura ■ Botox Injections ■ Interstim Therapy Prostate Prostate ■ Prostate Cancer ■ Signs and Symptoms ■ Early stages almost none ■ About 230,000 new cases per year in the U.S. ■ PSA elevation ■ 1 in 7 lifetime risk of “clinical” disease ■ Abnormal rectal exam ■ Results in about 30,000 annual deaths ■ Late stages can have bone pain and lower urinary tract ■ Second leading cause of male cancer deaths obstruction ■ Lung CA is still #1 ■ Diagnosis ■ Compares to breast cancer: ■ DRE and PSA ■ 216,000 cases/year ■ TRUS Bx ■ 40,000 deaths/year ■ CT and Bone Scan to eval for metastasis ■ 1 in 8 lifetime risk

Prostate Prostate ■ AUA guidelines ■ USPTF ■ PSA still indicated for men age 55-69 ■ Routine PSA screening is not indicated for any age group (Group D recommendation) ■ Should have annual DRE and PSA but some may elect to go every other year ■ Routine PSA screening did not show to increase either disease free survival or overall survival ■ No benefit to screening men <54 or >70 ■ Report sighted the risks of biopsy, ED, and ■ IF elevated above 4.0 or have increase of 0.75 or incontinence outweighed the benefits. more in 6 months, should have discussion of biopsy ■ Showed no changes in mortality in the screened groups Prostate Prostate ■ Prostate Cancer Treatment options ■ Benign Prostatic Hyperplasia ■ Watchful waiting ■ Increases in prevalence with age ■ Limited to men >75 or with <10 life expectancy ■ 50% by age 60 ■ Hormone Therapy ■ 80% by age 80 ■ About half with prostatic hypertrophy are symptomatic ■ Limited to stage T3 or T4 or PSA >50, suspect metastasis ■ Etiology: ■ Radiation Therapy ■ Multifactorial ■ Brachytherapy or XRT, T1 or T2, 80% long term survival ■ Surgical Management ■ Incompletely understood ■ Does require dihydrotestosterone and aging ■ Open or Robotic Prostatectomy ■ Cryo surgery or HIFU