1. health and fitness
2. disease
3. cancer

Five Common Urological
Problems Seen in Primaryy
Care
Jack H. Mydlo
Mydlo,, MD, FACS
Professor and Chair,, Dept
p of
Urology, Temple University
School of Medicine
Five most common problems

Voiding
g Dysfunction:
y
BPH obstruction, stricture, stone,
UTI, cancer, DM, etc.

Elevated PSA: BPH,
BPH prostatitis,
prostatitis UTI,
UTI

Erectile dysfunction: age, DM, HTN, smoking,

Hematuria: stones, UTI, tumors

Flank pain: stone, pinched nerve, cyst, spasm, weight
Problem # 1 Voiding Dysfunction
BOO (bladder outlet obstruction)










Urethral compression
p
Retained urine
Nocturia, frequency
N
Narrow
stream
Check fluid intake
Check for diabetes
Check for strictures
Check for CHF, etc.
Prostate CancerCancer-usually
asymptomatic
Hematuria
Treatment







Rule out medical problems and strictures
Check post void residual by ultrasound
Fl id restriction
Fluid
i i after
f di
dinner, void
id qhs
h
Alpha blocker alone, esp,
esp, if gland < 40 gms
Alpha blocker and finasteride if > 40 gms
Baseline PSA level
Can add antianti-cholinergic for symptoms if nl
PVR
Case A

67 year old male with increased nocturia

T k Tamsulosin
Takes
T
l i qhs
h but
b minimal
i i l
improvement

DRE: 50 g
grams,, smooth,, benign,
g , PSA nl

Drinks coffee and several sodas at night
Case A Evaluation and Plan

Decrease fluid after dinner,
dinner void before
bedtime

Sono to determine residual. Consider
adding
ddi Proscar
P
if gland
l d greater than
h 40
grams

Make sure no hx of STD’s: stricture
formation
Case B

48 year old female with urgency and
frequency. Hx of smoking

Failed ditropan 5 mg daily

Also complained
p
of stress urinaryy
incontinence

Drinks lot of tea and coffee
Case B Evaluation and Plan





Make sure she is on enough ditropan
ditropan,, can
go up to 15 mg
Can switch to Detrol,
Detrol Vesicare
Vesicare,,
Limit caffeine intake
For SUI, consider ImipramineImipramine-has
anticholinergic effect on detrusor, and
alpha--adrenergic effect on bladder neck
alpha
Urine cytology,
y
gy, check for hematuria
Case C

40 year old female presents cannot void

N other
No
h physical
h i l complaints,
l i
no h
hematuria
i

Non--smoker, non
Non
non--drinker

Exercises daily
Case C Evaluation and Plan

Check sono and post void residual to make
sure not dehydrated, R/O retention

Hx of energy drinks or drugs? BN spasm

Hx of stones or hematuria? Stone/clot
/
clog
g

Neurological exam: rule out MS: AUR 1st
Problem # 2 Elevated PSA
Made by epithelial cells,
cells not stromal cells
 Can be elevated in BPH, CAP, prostatitis,
UTI ejaculation,
UTI,
ejaculation not DRE
 Free PSA not as important as total PSA and
PSA velocity
l i ((> 00.55 ng
ng/dl/
/dl/yr
/dl/yr
 DRE is as important as
PSA to screen for CAP

Transrectal needle biopsy of
prostate (TRUS or finger guided)
Evaluation of Elevated PSA






Repeat to be sure
May consider course of antibx for wk,
wk, then
repeat
Negative bx does not R/O cancer!!! If PSA
still
ill elevated,
l
d 2ndd bx
b detects
d
24% missed
i d CA
Finasteride can increase detection (but ½
PSA)
Not everyone
y
with prostate
p
cancer needs Rx
General rule for CAP: > 70: RT, < 70: Surg
Case A

51 year old WM with PSA of 3.5, normal
DRE

TRUS Bx of prostate negative for cancer

Repeat PSA still elevated, what to do next?
Case A Evaluation and Plan




Free PSA not helpful compared to total PSA
22--24% off prostate cancers are d
22
detected
d 2ndd
time
Can give course of antibx to lower
inflammation, r/o UTI, ejaculation, etc
Can start Proscar to shrink gland, increase
detection of CaP
Case B: 55 year old male with GS
6 CaP

Sexually active

Medically healthy otherwise

Considers radiation vs surgery. What you
should know
Not the
Way to
Select
Treatment..
Surgery vs. Radiation
80%
70%
60%
50%
RRP
XRT
BTX
40%
30%
20%
10%
0%
5 yyr
10 yyr
> 10 yyr
External Beam Therapy/ 3D
Conformal Therapy
Prostate Brachytherapy
Hoffman et al, Am J Med 119:418,
2006
Surgery
Radiotherapy




81% 10 yr. survival
Incontinence: < 5%
ED: 45%

78% 10 yr survival

Proctitis, cystitis: 15%

ED: 4040-50%

Fistulas: 22--3%

Bladder Cancer: 0.6%
0 6%
Strictures: 8%
Complications of Radiation
Cystitis
Proctitis
Fistula Formation
Erectile Dysfunction
Bladder Cancer/Rectal Cancer
Robotic Surgery
RRP vs. RALP
Robotic Assisted Laparoscopic
Prostatectomy





ED incidence not different than open RP
SUI iincidence
id
not diff
different than
h open RP
Less blood loss
Quicker discharge to home
For best results, check experience of
surgeon
Case A Evaluation and Plan

Recommend surgery, discuss pros and cons
of open vs
vs. Robotic

Discuss risks of ED, SUI

Make sure partner is involved
Case B

72 year old male with GS 7,
7 PSA 8

H off MI
Hx
MI, on thinners,
hi
otherwise
h
i h
healthy
lh

Not sexually active

Life expectancy 15 years
Case B Evaluation and Plan

Consider radiation: compare external beam
(daily for 15 minutes, 5 days/wk
days/wk for a month

Brachytherapy, 1 ½ hours, OR, D/C in AM

Risks of recurrence,, cystitis,
y
,p
proctitis

Watchful waiting or consider surgery (> 15)
Problem # 3 Erectile
Dysfunction




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
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Hypertension: re
re--adjust BP meds
Diabetes
Smoking: #1 preventable cause
A
Age
Lipid profile
Psychological
Low libido: no testosterone if > 400 dl/ml
Erectile Dysfunction
Vascular Causes
Structural Changes
Atherosclerosis
Hypertension
Hypercholesterolemia
Functional Changes
Impairment of
endothelium-dependent
relaxations
Diabetes
Impairment
of neurogenic
relaxations
Arteries
Arterial
stenosis
Arterial insufficiency
Arteries
Impaired
p
vasodilation
Reduced inflow
Trabeculae
Smooth muscle
atrophy and
fibrosis
Excessive outflow
Corporo-venoocclusive disease
Trabeculae
Impaired
relaxation
Adapted from Tejada I et al. In: Erectile Dysfunction. Plymbridge Distributors; 2000:65
Reassurance for ED






“Is
Is it too small?
small?” Self doubt is biggest
enemy of the penis. If you think small, you
are small.
small
Women complain if too big, not if too small
E
Every
male
l h
has llost erection
i
Every male has failed to satisfy a partner
Men take this in stride: happier, healthier
Avoid boredom: different positions, different
rooms, “anger/boredom can lead to ED”
Case A

47 year old male with 6 month history of ED

Ph i ll fi
Physically
fit, nonnon-smoking,
ki
married
i d 20 yrs

Stress at work and home. Has morning
erections

Good libido
libido, normal serum testosterone
Case A Evaluation and Plan

Could try PDE5i
PDE5i, make sure he is educated
about the usage: empty stomach, no alcohol,
must be aroused,
aroused may need several attempts

P h l i l IIntervention?
Psychological
i ? (AM erections)
i )

If testosterone was low, can add hormone
supplement,
pp
, can salvage
g 35% of failures
Case B

58 yo overweight male w 2 year hx of ED

T ll you h
Tells
he h
has tried
i d all
ll three
h
PDE5i w
failure

Hx of high
g blood pressure,
p
, diabetes &
smoking

Happily married
Case B Evaluation and Plan

Lose weight! Adipose tissue converts
testosterone to estrogen

Stop smoking! #1 preventable/reversable
preventable/reversable
cause

Re--educate about PDE5
Re
PDE5--i therapy: empty
stomach, up to 55-6 attempts, arousal
Case B Evaluation and Plan



If meds still don
don’tt work,
work offer vacuum pump
combination
Offer MUSE (alprostadil
(alprostadil urethral
suppository
Off EDEX or Caverjet
Offer
C
j injection
i j i therapy
h
Case C

52 year old WM on dialysis, on nitrates

Still smokes cigarettes

Getting married soon, wishes to correct ED
Case C Evaluation and Plan




Case start self injection w EDEX or Caverjet
Can sometimes combine with PDE5i (but
not if on nitrates)
Can combine with vacuum therapy rehab
If fails, consider penile prosthesis
Problem # 4 Hematuria

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

Causes: Stones, bladder cancer, BPH.
E l
Evaluate
smoking
ki hx
h , dyes,
hx,
d
other
h chemicals.
h i l
Make sure you have a “clean catch” urine
Send a urine cytology
Baseline renal/bladder sonogram
Needs urologic workup: CT, cysto,
cysto, cytology
Case A

60 yo female had gross hematuria from
“UTI”

It resolved when her UTI was treated with
antibiotics
ibi i

Smoked 2 PPD for 40 years

On blood thinners
Case A Evaluation and Plan

Urine cytology

CT off abdomen
bd
and
d pelvis
l i w/
/ and
d w/o
/
contrast

Cystoscopy
y
py
Case A Results

CT revealed
l db
benign
i renall cyst

Cystoscopy revealed cystitis
Case B

65 year old female with hx of smoking

G
Gross
and
d microhematuria
i h
i

On thinners

No hx of trauma
Case B Evaluation and plan

R exophytic lesion 5
cm

Contralateral kidney
OK

No major
j health issues
Case B Evaluation and Plan





Watchful waiting for lesions < 3 cm
C
Cryoablation
bl i or RFA for
f older,
ld ffrail
il patients
i
Right nephrectomy possible, but overkill
Right partial nephrectomy best choice
Still needs cystoscopy to rule out other
pathology
Case C

77 year old male with gross hematuria

H off prostate cancer 10 years ago, had
Hx
h d XRT

Symptoms of frequency, urgency, BOO

Worked in oil refinery business
Case C Evaluation and Plan




Urine cytology suspicious for malignancy
CT negative
i for
f llesions
i
iin kid
kidney and
d
bladder
PSA 2.2
Hx of HTN,, DM,, no MI or CVA
Case C Evaluation and Plan


Refer to urologist
Cystoscopy reveals bladder tumor
Problem # 5 Flank pain





Causes: stones,
stones UPJ obstruction,
obstruction renal
tumor, large renal cysts, aortic aneurysm
lumbar disc disease
Distinguish low back pain from flank pain
If hx
h off small
ll renall cyst, b
be wary: rarely
l the
h
cause of back pain
Sonogram, CT can be most helpful
Be waryy of drug
g seekers,, Munchausen’s,, etc
Renal Cysts: Bosniak Classification:
1
Complex Cysts: Bosniak
Classification 2, 3, 4
2: 10% malignancy
3: 20-40%
4: 90% malignancy
Ureteral stone
Ureteral stone

Hydration Flomax if less than 6 mm,
Hydration,
mm or
recurrent

Lemonade (citric acid) prevents future
stones

If febrile: MUST GO TO ER FOR STENT
PLACEMENT or PERC,, and IV ATBX!
Renal Stone Treatments:
py, ESWL PCNL
Ureteroscopy,
Other causes of Flank Pain: UPJ
obstruction, AAA, Disc Disease
Case A





46 year old female with complaints of
chronic flank pain
On PE, appears to be midline, no CVAT
No blood in urine
No fevers,, chills,, N or V
Sonogram negative for stone
Case A Evaluation and Plan

CT scan revealed herniated lumbar disc

Referred to neurosurgery for further
evaluation
Case B

50 year old male referred for left flank pain

CT scan revealed
l d llarge lleft
f renall cyst 12 cm

CVAT lateralized to left

No major medical issues
Case B Evaluation and Plan

Interventional Radiology to aspirate cyst

If pain resolves, then cyst is cause of pain. If
no resolution, another cause for pain.

Consider surgical unroofing of cyst if cause
Case C





50 year old nurse’s aid presents to office
Friday PM c/o flank pain
Imaging ((--) for stone, cyst or hydronephrosis
States she had fevers at home, now afebrile
States hx of hematuria,, but U/A
/ neg
g now
Initially very nice, but increasingly hostile
Reassurance



Classic Munchausen’s syndrome: medical
background history & symptoms “too
background,
classic”
D
Demands
d attention
i and
d more procedures
d
(i
(in
urology, sexual gratification from instrument
i
insertion)
i )
High rate of malpractice claims
Thank you

jmydlo@temple.edu
Questions
Question # 1

PSA can be elevated due to:

UTI
Prostatitis
Ejaculation
BPH
All of the above
N
None
off the
h above
b





Question # 1

PSA can be elevated due to:

All of the above
Question # 2

Erectile dysfunction
dysfunction, if found to be present
in a male with heavy smoking history

Can be improved or reversed upon cessation
off smoking
ki after
f 11--2 years
Will always need prosthesis since meds
won’t work
Is p
purelyy p
psychological
y
g
Has no good options



Question # 2

Erectile dysfunction
dysfunction, if found to be present
in a male with heavy smoking history

Can be improved or reversed upon cessation
off smoking
ki after
f 11--2 years
Question # 3

Localized prostate cancer
cancer, in general
general, can be
treated by:

Watchful waiting
External beam radiation or brachytherapy
Open
p surgery
g y or robotic surgery
g y
Treatment varies by age, health, desires of
patient
All of the above




Question # 3

Localized prostate cancer
cancer, in general
general, can be
treated by:

All of the above
Question # 4

Renal stones:

All must b
be treated
d surgically
i ll
Should not have trial of hydration if < 6 mm
Needs immediate stent or PCN if febrile
Never cause hematuria



Question # 4

Renal stones:

Needs immediate stent or PCN if febrile
Question # 5
Treatment of symptoms of BPH,
BPH including
nocturia,, include:
nocturia





Fluid restriction after dinner & voiding qhs
Evaluation of medical issues (DM, CKD)
Alpha
p blocker +/+/
/- finasteride
All of the above
None of the above
Question # 5
Treatment of symptoms of BPH,
BPH including
nocturia,, include:
nocturia

All of the above
Thank you

jmydlo@temple.edu