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

Pitfalls of Urology for the Gatekeeper

What are they and how to avoid them David A. Anderson, MD Ferrell Duncan Clinic, 2016

David A. Anderson, MD

■ Born in Sioux City, Iowa ■ Undergraduate studies at Taylor University ■ Medical School at University of Iowa College of

Medicine

■ Internship and Residency at University of Iowa

Hospitals and Clinics

■ Joined Ferrell Duncan Clinic, Springfield MO in 2005 ■ Interests include Robotics, Minimally invasive surgery

and treatments of Incontinence

Objectives

■ Hopefully you will be able to…

■ Identify common clinical urologic presentations ■ Establish a quick differential diagnosis ■ Develop a diagnostic plan and execute treatment or

refferal

■ Hopefully you will not…

■ Be offended by my sense of humor ■ Be grossed out by pictures of scrotums ■ Fall asleep out of complete boredom

Anatomic Approach to Urologic Pathology

■ Kidney ■ Renal Cell/Urothelial Cell

Tumors

■ Nephrolithiasis ■ Congenital obstructions/

Hydronephrosis

■ Pyelonephritis ■ Renal Cyst ■ Bladder ■ Urothelial Malignancies ■ Cystitis ■ Bladder Stones ■ Interstitial Cystitis ■ Asymptomatic Bacteruria ■ Incontinence

■ Stress ■ Urge ■ Overflow

Anatomic Approach to Urologic Pathology

■ Prostate ■ Prostate Cancer ■ BPH ■ Prostatitis ■ Penis ■ Penile Cancer ■ Penile Trauma ■ Phimosis/Paraphimosis ■ Testicle

■ Testicular Cancer ■ Testicular Torsion ■ Epididymitis/Orchitis ■ Orchalgia ■ Spermatocele ■ Hydrocele ■ Varicocele ■ Undescended Testicle

Clinical Approach to common Urologic pathology

■ Hematuria ■ Definition, workup, common findings ■ Elevated PSA ■ Current recommendations, workup and causes ■ Flank Pain ■ Differential dx, work up, referral ■ Recurrent UTI’s ■ Causes, work up, treatment options ■ Pelvic Pain ■ Differential dx, work up and treatment options

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

■ Hematuria (40-60%) ■ Flank pain (30-40%) ■ Weight loss (33%) ■ Anemia (33%) ■ Palpable mass (25%)

■ Diagnostic Studies

■ CT Ab/Pelvis w/ contrast ■ MRI ■ U/S

Kidney

■ Renal Cell Cancer Treatment

■ Surgery in cases without distant spread

■ Laparoscopic vs. Open Radical Nephrectomy ■ Robotic vs. Open Partial nephrectomy ( Tumors <4 cm)

■ Radiation therapy

■ Not very effective, almost no role

■ Chemotherapy

■ Not very effective

■ Immunotherapy

■ Not very effective, shown to add 2-4 months avg life expectancy

Kidney

■ Nephrolithiasis

■ Requires “supersaturation” of urine with an insoluble

material such as calcium oxalate or cysteine

■ More likely if...

■ Urine flow is low (water conservation) ■ Mineral (esp. calcium salts) production is high ■ Urine mineral concentration is high

■ Idiopathic (hereditary) hypercalciuria

■ Deficit of mineral dissolvers such as Citrate

Kidney

■ Kidney stones

■ May detach and lodge in

the ureter

■ Acute pain syndrome ■ Hydronephrosis due to

complete occlusion

■ May grow to large to pass

& fill renal pelvis

■ “Staghorn calculi”

Kidney

■ Clinical Presentation of Stones

■ PAIN!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

■ Flank to lower quadrant as the stone passes ■ Colicky in nature, usually 12/10 pain ■ Pain that narcotics wont help

■ Nausea and Vomiting ■ Hematuria ■ Urgency and frequency if stone is distal ■ Testicular pain, pelvic pain

Kidney

■ Treatment options for Stones

■ Ureteroscopy

■ Using a scope to extract stone either with a basket or with

a laser

■ Only risk in ureteral injury

■ Lithotripsy

■ Very effective (95%) with only sedation ■ May cause renal damage

■ Percutaneous Nephrolithotripsy

■ 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

■ 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

■ Hematuria

■ Often gross but may be

microscopic

■ Presenting symptom in

85-90%

■ Irritative voiding

symptoms

■ Pain, masses with

advanced disease

Bladder

■ Diagnosis

■ Hematuria on UA leads to

either IVP or CT Ab/ Pelvis and Cystoscopy

■ Transurethral Resection

may be curative depending

• n stage

■ Most (50-80%) bladder cancers will

be superficial at diagnosis:

■ CIS, Ta, T1

■ Advanced disease:

Cystectomy vs Chemo/ XRT

Bladder

■ UTI

■ Simple/Uncomplicated UTI

■ Cystitis in female, no other factors ■ Lower urinary tract involved, no fever, local symptoms

■ Complicated UTI

■ Cystitis in Male, pyelonephritis, catheterized patients,

immunocompromised patients, or other factors

■ Upper tract involvement, instrumentation, catheters,

neurogenic bladders

Bladder

■ UTI Signs and Symptoms

■ “Irritative voiding symptoms”

■ Urinary frequency, urgency, pain (dysuria)

■ Hematuria (may be microscopic) ■ Fever: most common in children

■ Pyelonephritis

■ Fever, nausea, vomiting, flank pain

■ UA

■ Presence of WBC and Bacteria on UA, Nitrite +,

Leukocyte esterase +, CULTURE

Bladder

■ UTI Diagnosis

■ UA

■ + WBC, +/- RBC ■ +Nitrite ■ +Leukocyte esterase ■ + Bacteria

■ Culture

■ >100,000 CFU/HPF of

bacteria ■ Dipstick + Urine is

correct 20% of the time!!

Bladder

■ Asymptomatic Bacteruria

■ Common in the elderly ■ General recommendation is to not treat unless

patient becomes symptomatic

■ Fever, constitutional symptoms, dysuria, irritative

symptoms

■ Also common in pregnancy

■ Usually treated to avoid pyelonephritis ■ Also associated with premature labor

Bladder

■ Treatment

■ Uncomplicated UTI

■ 3-5 days of TMP/SMZ ■ Hydration, AZO

■ Complicated UTI

■ 10-14 days of TMP/SMZ or Flouroquinolone ■ May need cephalosporin or augmentin ■ Change catheter or stent

■ Pyelonephritis

■ 14-21 days of flouroquinolone ■ May need IV abx w/ or w/o hospitalization

Bladder

■ Urinary Incontinence

■ Stress Incontinence

■ Intrinsic urethral sphincter deficiency from age,

hysterectomy and multiple vaginal deliveries

■ Urge incontinence

■ Overactivity of M2 and M3 receptors in the bladder

causing an increase in contraction of detrusor

■ Can be cause by detrusor dysfunction from MS, diabetes or

sacral nerve injury

■ Most commonly idiopathic but must rule out infection and

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 Cancer

■ About 230,000 new cases per year in the U.S.

■ 1 in 7 lifetime risk of “clinical” disease

■ Results in about 30,000 annual deaths ■ Second leading cause of male cancer deaths

■ Lung CA is still #1

■ Compares to breast cancer:

■ 216,000 cases/year ■ 40,000 deaths/year ■ 1 in 8 lifetime risk

Prostate

■ Signs and Symptoms

■ Early stages almost none ■ PSA elevation ■ Abnormal rectal exam ■ Late stages can have bone

pain and lower urinary tract

• bstruction

■ Diagnosis

■ DRE and PSA ■ TRUS Bx ■ CT and Bone Scan to eval for

metastasis

Prostate

■ AUA guidelines

■ PSA still indicated for men age 55-69 ■ Should have annual DRE and PSA but some may

elect to go every other year

■ No benefit to screening men <54 or >70 ■ IF elevated above 4.0 or have increase of 0.75 or

more in 6 months, should have discussion of biopsy

Prostate

■ USPTF

■ Routine PSA screening is not indicated for any age

group (Group D recommendation)

■ Routine PSA screening did not show to increase

either disease free survival or overall survival

■ Report sighted the risks of biopsy, ED, and

incontinence outweighed the benefits.

■ Showed no changes in mortality in the screened groups

Prostate

■ Prostate Cancer Treatment options

■ Watchful waiting

■ Limited to men >75 or with <10 life expectancy

■ Hormone Therapy

■ Limited to stage T3 or T4 or PSA >50, suspect metastasis

■ Radiation Therapy

■ Brachytherapy or XRT, T1 or T2, 80% long term survival

■ Surgical Management

■ Open or Robotic Prostatectomy ■ Cryo surgery or HIFU

Prostate

■ Benign Prostatic Hyperplasia

■ Increases in prevalence with age

■ 50% by age 60 ■ 80% by age 80 ■ About half with prostatic hypertrophy are symptomatic

■ Etiology:

■ Multifactorial ■ Incompletely understood ■ Does require dihydrotestosterone and aging

Prostate

■ Obstructive Symptoms

■ Decreased force & caliber

• f urine stream

■ Difficulty initiating flow

(“hesitancy”)

■ Sensation of incomplete

emptying

■ Double voiding (2nd void

within 2 hours)

■ Straining to urinate ■ Post-void dribbling

■ Irritative Symptoms

■ Urgency ■ Frequency ■ Nocturnal voiding ■ All due to bladder pressure

changes from partial

• utflow tract obstruction

Prostate

■ Observation

■ About 1/3 of men with BPH will experience

improved symptoms over time

■ Herbs, dietary

■ Herbs, esp. saw palmetto allegedly reduce BPH

■ Medical treatment

■ Alpha blocker drugs and 5-alpha reductase inhibitors

■ Surgical treatment

■ TURP, TURIS, TUNA, TUMT

Prostate

■ Surgical Management

■ TURP ■ TURIS ■ TUMT ■ TUNA ■ Open Simple

prostatectomy

Prostate

■ Acute Prostatitis

■ Enlarged (swollen) and very painful prostate ■ Leukocytosis with left shift ■ U/A: pyuria, bacturia, some hematuria ■ Cultures: positive growth from urine and blood

■ Exam findings

■ Perform digital rectal exam gently!! ■ Prostate massage and excessive palpation are

contraindicated (can result in septicemia)

Prostate

■ Acute Prostatitis Treatment

■ Some patients may need to be hospitalized

■ Esp. those with high fever, nausea ■ IV antibiotics: ampicillin & aminoglycoside (e.g.

gentamicin)

■ Outpatient antibiotics:

■ Fluroquinolone antibiotics such as…. ■ Ciprofloxacin (Cipro) ■ Usually need an extended course of up to 6 weeks

Prostate

■ Chronic Prostatitis

■ More common in middle aged men 40 - 60 yr old ■ Typical symptoms:

■ Irritative voiding symptoms ■ Low back pain, perineal pain ■ NO_FEVER! ■ Intermittent recurrent pattern

■ Very few cases are due to chronic low grade bacterial

infections

■ Some are due to atypical infectious agents

■ Many/most are due to non-specific inflammation

Prostate

■ Chronic Prostatitis

■ Offending organisms:

■ Gram negative rods

■ Urine & blood cultures negative ■ Prostatic secretions show leukocytes and

bacteria

■ Best treatment:

■ Trimethoprin-sulfamethoxazole for 6 – 12 weeks ■ Ibuprofen 600-800 mg TID PRN for 3 weeks

Penis

■ Penile Cancer- Squamous cell carcinoma

■ The exact cause is unknown. ■ Smegma, a cheese-like, foul-smelling substance found

under the foreskin of the penis may increase the risk

• f penis cancer.

■ Uncircumcised men who do not keep the area under

the foreskin clean and men with a history of genital warts or human papillomavirus (HPV) are at higher risk for this rare disorder

Penis

■ Symptoms

■ Sores on the penis ■ Penis pain and bleeding from the penis (may occur

with advanced disease)

■ Signs and tests

■ physical exam, which may reveal a non-tender lesion

that looks like a pimple or wart. This growth is typically near the end of the penis.

■ A biopsy of the growth is needed to determine if it is

cancer.

Penis

■ Treatment

■ Local invasion requires

surgical intervention

■ Excision of lesion ■ Partial penectomy ■ Total penectomy with

perineal urethrostomy

■ Distant or advanced

disease requires chemotherapy or radiation therapy

■ Cisplatin, ifosfamide and

paclitaxel

Penis

■ Phimosis

■ Redundant and narrowing

• f the foreskin

■ Caused by repeated

episodes of balanitis

■ Treatment is either dorsal

slit or circumcision

■ Paraphimosis

■ occurs when the foreskin

• f an uncircumcised male

cannot be pulled back over the head of the penis

■ Treatment of

paraphimosis involves compression of the foreskin to reduce

• swelling. IF unsuccessful

urgent surgical treatment needed

Testicle

■ Testicular Cancer

■ About 9,000 new cases

each year in the U.S.

■ Few deaths, however

(typically <500)

■ More common in

Caucasians

■ Peak incidence age is

15-40

■ Pathology

■ Almost all are derived

from germ cells

■ Two main types: ■ About one third are

Seminomas

■ The other two-thirds are

Non-seminomas

■ Embryonal cell ■ Teratoma ■ Choriocarcinoma

Testicle

■ Cryptorchism

■ Account for 5% of cases ■ Orchiopexy recommended

before puberty but does not reduce tumor risk!

■ Symptoms

■ Painless testicular mass ■ Malaise, weight loss,

fatigue in advance disease

Testicle

■ Testicular Torsion

■ Sudden twisting of testicle

cutting off blodd supply

■ Symptoms

■ Acute onset of unilateral

testis pain

■ Nausea, VOMITING

■ Diagnosis

■ Scrotal u/s showing no flow ■ Needs urgent surgical

exploration to preserve

Testicle

■ Epididymitis/Orchitis

■ Bacterial infection of

epididymis or testicle

■ Symptoms

■ Unilateral swelling, pain,

erythema, induration of scrotum

■ Diagnosis

■ Scrotal u/s showing

increased blood flow but no abcess

■ Treatment

■ 4-6 weeks of

flouroquinolone (Cipro)

Testicle

■ Spermatocele

■ Dilation of the

epididymimal tubual

■ Usually assymptomatic till

large enough to need surgery

■ Hydrocele

■ Fluid filled sack around

testicle

■ Results from infection or

injury

■ Diagnose both with U/S

Testicle

■ Varicocele

■ Dilation of veins draining

testicle

■ Usually assymptomatic ■ Increase incidence in

patients with infertility

■ Treat with microscopic

clipping of veins while preserving arterial flow

Hematuria

■ Two microscopic urinalysis that show 2-5 RBC/

HPF in a non infected clean catch urine

■ Workup should be either IVP or Ab/Pelvis CT

urogram and Cystoscopy

■ Renal u/s is not enough

■ Looking for: Renal malignancies, stones, upper

tract urothelial ca, bladder ca, bladder stones

Elevated PSA

■ AUA: any PSA > 4.0 in a male age 50-72 or any

PSA that increases in 0.75 in 6 months

■ USPTF: Routine PSA is no longer indicated ■ Educate patients about risks and benefits of PSA

■ Risks are infection (10% risk of hospitalization from

infection), bleeding, and pain from biopsy

■ Benefit is early detection of potentially curable

cancer

Flank Pain

■ Pain in side or flank that radiates to groin, testicle

• r suprapubic area is often urologic

■ Differential Diagnosis

■ Diverticulitis, musculoskeletal back pain,

endometriosis, orchitis/epididymitis, kidney stone, ureteral obstruction

■ Imaging should include IVP and or CT urogram ■ Refer if urologic source found

Recurrent UTI’s

■ Recurrent UTI

• Most common in young adult women
• Strategies to prevent recurrences:
• Empty bladder before intercourse, then hydrate after
• Antibiotic before intercourse or morning after
• Long term low dose antibiotic therapy
• Single strength bactrim qhs or Macrodantin 50mg qhs

Need and IVP and cysto to rule out any upper tract pathology

Pelvic Pain

■ Rarely urologic in origin other than Interstitial

cystitis

■ Bladder malignancies rarely cause pain ■ Kidney stones almost always are flank or groin in

• rigin

■ Pelvic U/S or CT is appropriate and then refer

Wake UP! Were done! Questions?