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Urology Back to Basics The “Nuts” and Bolts

Urology Back to Basics The “Nuts” and Bolts. James Watterson, MD FRCSC Assistant Professor, University of Ottawa Director, Ottawa Lithotripsy and Stone Program Endourology and Laparoscopic Urological Surgery Division of Urology, The Ottawa Hospital. References.

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Urology Back to Basics The “Nuts” and Bolts

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  1. Urology Back to BasicsThe “Nuts” and Bolts James Watterson, MD FRCSCAssistant Professor, University of Ottawa Director, Ottawa Lithotripsy and Stone Program Endourology and Laparoscopic Urological Surgery Division of Urology, The Ottawa Hospital

  2. References • The Medical Council of Canada • www.mcc.ca • Objectives for the Qualifying Examination • MCC Objectives.doc • University of Toronto Notes • Campbell’s Urology

  3. Objectives • The Medical Council of Canada • Abdominal Mass • Adrenal Mass • Blood in Urine (Hematuria) • Gynecomastia • Ambiguous Genitalia • Infertility • Incontinence, Urine • Incontinence, Urine, Pediatric (Enuresis) • Impotence, Erectile Dysfunction • Acute and Chronic Renal Failure (Post-renal / Obstruction) • Scrotal Mass / Scrotal Pain • Urinary Tract Injuries • Dysuria and / or Pyuria • Urinary Obstruction / Hesitancy / Prostatic Cancer

  4. Objectives • The Medical Council of Canada • Abdominal Mass • Adrenal Mass • Blood in Urine (Hematuria) • Gynecomastia • Ambiguous Genitalia • Infertility • Incontinence, Urine • Incontinence, Urine, Pediatric (Enuresis) • Impotence, Erectile Dysfunction • Acute and Chronic Renal Failure (Post-renal / Obstruction) • Scrotal Mass / Scrotal Pain • Urinary Tract Injuries • Dysuria and / or Pyuria (UTI) • Urinary Obstruction / Hesitancy / Prostatic Cancer

  5. Blood in Urine (Hematuria) Key Objective (s): Differentiate red or brown urine from hematuria, transient from persistent, and glomerular from extraglomerular hematuria

  6. Hematuria Objectives Through efficient, focused, data gathering • Determine whether the patient has true hematuria • Diagnose the presence of urinary tract infections • Differentiate between glomerular and extraglomerular hematuria by examination of urine sediment List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis • Interpret reported urinalysis findings • Outline significance of patient’s age, gender and life style on diagnostic possibilities Conduct an effective plan of management for a patient with hematuria • Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract • Outline a plan for investigation of patients with recurrent nephrolithiasis • Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis • Discuss possible strategies for the detection and prevention of urinary tract tumors

  7. Hematuria Objectives Through efficient, focused, data gathering • Determine whether the patient has true hematuria • Diagnose the presence of urinary tract infections • Differentiate between glomerular and extraglomerular hematuria by examination of urine sediment List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis • Interpret reported urinalysis findings • Outline significance of patient’s age, gender and life style on diagnostic possibilities Conduct an effective plan of management for a patient with hematuria • Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract • Outline a plan for investigation of patients with recurrent nephrolithiasis • Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis • Discuss possible strategies for the detection and prevention of urinary tract tumors

  8. HematuriaConsiderations • Pseudohematuria • Menses • Dyes (ie. Anthrocyanin in beets, rhodamine B in drinks, candy and juices) • Hemoglobinuria (hemolytic anemia) • Myoglobinuria (rhabdomyolysis) • Drugs (rifampin, phenazopyridine) • Porphyria (brownish urine) • Laxatives (phenolphthalein) • Urine dipstick – if positive, indicates hematuria, hemoglobinuria, or myoglobinuria • Microscopy distinguishes hematuria from Hgburia or Mgburia

  9. Hematuria Objectives Through efficient, focused, data gathering • Determine whether the patient has true hematuria • Diagnose the presence of urinary tract infections • Differentiate between glomerular and extraglomerular hematuria by examination of urine sediment List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis • Interpret reported urinalysis findings • Outline significance of patient’s age, gender and life style on diagnostic possibilities Conduct an effective plan of management for a patient with hematuria • Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract • Outline a plan for investigation of patients with recurrent nephrolithiasis • Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis • Discuss possible strategies for the detection and prevention of urinary tract tumors

  10. UTI • History & P/E • Irritative voiding symptoms (dysuria, freq, urg, suprapubic pain, hematuria) • Fever • Flank pain • Inspection of urine – Turbid • May be secondary to excessive phosphates • Urinalysis • Dipstick • Leukocyte esterase • Nitrites • Microscopic analysis • False-negative (low numbers bacteria), false-positive (normal vaginal flora; NB squamous epithelial cells indicate contamination) • > 2 WBCs/HPF correlates with presence of bacteriuria • RBCs lack sensitivity (40-60% cases of cystitis) but highly specific • Urine culture • mid-stream vs. catheterized specimen • Traditionally, > 105 cfu/mL • In dysuric patients, 102 cfu/mL of a known pathogen significant Limited sensitivity

  11. Hematuria Objectives Through efficient, focused, data gathering • Determine whether the patient has true hematuria • Diagnose the presence of urinary tract infections • Differentiate between glomerular and extraglomerular hematuria by examination of urine sediment List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis • Interpret reported urinalysis findings • Outline significance of patient’s age, gender and life style on diagnostic possibilities Conduct an effective plan of management for a patient with hematuria • Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract • Outline a plan for investigation of patients with recurrent nephrolithiasis • Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis • Discuss possible strategies for the detection and prevention of urinary tract tumors

  12. HematuriaMCC Causal Conditions • Transient • Urinary tract infections • Exercise induced • Stones/Crystals • Trauma • Endometriosis • Thromboembolism • Anticoagulants (similar incidence of hematuria in non-anticoagulated patients) • Persistent • Extraglomerular (Urological) • Renal • Tumors • Tubulointerstitial diseases (e.g polycystic kidneys, pyelonephritis) • Vascular (e.g. papillary necrosis, sickle cell disease) • Collecting system • Tumors • Stones • Lower urinary tract • Glomerular • Isolated (e.g. IgA nephropathy, thin membrane disease) • Post-infections (e.g. post-streptococcal) • Systemic involvement (e.g. vasculitis, SLE)

  13. Figure 3-7 Evaluation of nonglomerular renal hematuria (circular erythrocytes, no erythrocyte casts, and proteinuria). CT, computed tomography; IgA, immunoglobulin A; IVU, intravenous urography; PT, prothrombin time; PTT, partial thromboplastin time; R/O, rule out.

  14. Figure 3-6 Evaluation of glomerular hematuria (dysmorphic erythrocytes, erythrocyte casts, and proteinuria). ANA, antinuclear antibody; ASO, antistreptolysin O; Ig, immunoglobulin.

  15. Hematuria Diagnostic Evaluation: Is it? • True or False • Extraglomerular vs. Glomerular • Dysmorphic RBCs • Casts (RBC, WBC) • Proteinuria (>100-300 mg/dL or 2+ to 3+ on dipstick) • Gross or Microscopic • > 3 RBC / HPF • Further Urological Questions • Location- Renal/Ureter/Bladder/ Prostate/Urethra • Painful/Painless • Part of Stream- Initial/Terminal/Throughout ??? • Clots – shape of clots

  16. Investigations for Hematuria • History and P/E • Smoking • Other risk factors for urothelial malignancy • Urine • Urinalysis / Microscopy / C & S • Cytology • Upper tract • Microscopic • Renal U/S • Gross • CT urogram • Lower tract • cystoscopy

  17. HematuriaDDx • VINDICATE • Renal/Ureter/Bladder/Prostate/Urethra • Neoplasm.. Neoplasm.. Neoplasm • Stone • Trauma • Infection

  18. Hematuria Objectives Through efficient, focused, data gathering • Determine whether the patient has true hematuria • Diagnose the presence of urinary tract infections • Differentiate between glomerular and extraglomerular hematuria by examination of urine sediment List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis • Interpret reported urinalysis findings • Outline significance of patient’s age, gender and life style on diagnostic possibilities Conduct an effective plan of management for a patient with hematuria • Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract • Outline a plan for investigation of patients with recurrent nephrolithiasis • Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis • Discuss possible strategies for the detection and prevention of urinary tract tumors

  19. UTITreatment • Principles of Antimicrobial Therapy • Effective antimicrobial therapy must eliminate bacterial growth • Antimicrobial resistance is increasing because of excessive utilization • Antimicrobial selection should be influenced by efficacy, safety, cost and compliance • Lower Tract UTI – cystitis; most occur in women; 10% incidence • Bacteria – E.coli causative organism in 75 – 90% of acute cystitis in young women • Drug choices • TMP-SMX DS BID 3 days • Nitrofurantoin 100mg BID 3 days • Norfloxacin 400mg BID 3 days • Ciprofloxacin 500mg BID 3 days

  20. UTITreatment • Recurrent Lower Tract UTI in Women • Self-start Rx • Post-coital single dose • Low dose prophylaxis 3-6 months • Upper Tract UTI (Acute Pyelonephritis) • E.coli accounts for 80% of cases • Blood cultures positive in 25% • Consider U/S or CT if failure to respond after 72 hrs of therapy • Rx • Uncomplicated – Cipro 500mg BID PO, Levofloxacin 500mg QD PO x 7 – 10 days • Complicated – Parenteral Cipro, Levo, Amp + Gent x 7 – 10 days

  21. Hematuria Objectives Through efficient, focused, data gathering • Determine whether the patient has true hematuria • Diagnose the presence of urinary tract infections • Differentiate between glomerular and extraglomerular hematuria by examination of urine sediment List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis • Interpret reported urinalysis findings • Outline significance of patient’s age, gender and life style on diagnostic possibilities Conduct an effective plan of management for a patient with hematuria • Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract • Outline a plan for investigation of patients with recurrent nephrolithiasis • Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis • Discuss possible strategies for the detection and prevention of urinary tract tumors

  22. Risk Factors for Stone Disease • Diet, Diet, Diet • Dehydration • High protein intake • High salt intake • Certain foods high in oxalate • Occupation • Dehydration • Inflammatory Bowel Disease, Gout, Hyperparathyroidism • Genetics • Rarely • Recurrent nephrolithiasis • Refer to urologist or nephrologist • Metabolic evaluation • Serum chemistry (Lytes, BUN, Cr, Ca, Urate, PTH) • 24 hour urine (Lytes, Ca, Oxalate, Uric acid, citrate, Mg, cystine)

  23. Dysuria and/or Pyuria Key Objective (s): Differentiate between urinary tract infections and conditions outside the urinary tract with similar presentation; determine which infections require treatment, and select the appropriate treatment. In patients with recurring urinary tract infections, determine whether a predisposing condition may be present (e.g., stasis from obstruction, reflux).

  24. Dysuria and/or Pyuria • Through efficient, focused, data gathering: • Interpret urinalysis and clinical findings in order to diagnose problems external to urinary tract. • Evaluate examination findings so that problems involving the urethra or prostate are identified. • Determine whether cystitis or pyelonephritis is the more likely diagnosis. • List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis: • Outline significance of patient's age, gender, and life style on diagnostic possibilities. • Select findings which are best for differentiating cystitis from pyelonephritis. • Describe the collection of samples to be sent for culture and sensitivity; interpret results. • Conduct an effective plan of management for a patient with urinary frequency, dysuria, and/or pyuria: • Determine which patients require additional investigation and/or referral. • Determine which patients require hospitalization. • Determine which patients should be on prophylactic treatment and the type of treatment. • Select the most appropriate treatment for the underlying condition. • List conditions which predispose to urinary tract infections. • Outline strategies for prevention of recurrent urinary tract infections.

  25. Dysuria and/or Pyuria • Dysuria = painful urination • Usually caused by inflammation • Commonly referred to the urethral meatus • Start: may indicate urethral • End (stranguria): usually bladder origin • Usually accompanied by frequency and urgency • Pyuria = presence of white blood cells (WBCs) in urine • Generally indicative of infection and an inflammatory response of the urothelium to the bacterium • Bacteriuria without pyuria is generally indicative of bacterial colonization without infection • Pyuria without bacteriuria warrants evaluation for TB, stones, or cancer

  26. Dysuria and/or PyuriaDDx • Vesical • Bacterial cystitis • Bladder tumor / CIS • Bladder stone • TB cystitis • Radiation cystitis • Nonbacterial cystitis • Cyclophosphamide / ASA / NSAID / Allopurinol Dysuria / Freq / Urgency >> Vesical vs. Extravesical • Extravesical • Urological • Urethral diverticulum / CA • Prostatitis • Urethritis • Lower ureteral stone • Gyne • Vulvovaginitis • Herpes • Endometriosis • Ovarian / Uterine / Cervical CA • Bowel • Diverticulosis • Fistula • Crohn’s • Colon CA

  27. Dysuria and/or PyuriaEvaluation Dysuria / Freq / Urgency >> Vesical vs. Extravesical • History • Age, Gender, Smoking History • LUTS • PMHx (Gyne, IBD, divertic), PSHx (pelvic), PGUHx (UTI, STD, Tumor, Stone, Hematuria) • Physical examination • Suprapubic tenderness • Genital exam • Rectal exam (prostate, rectum) • Pelvic exam • Investigations • Urine (U/A, C&S, cytology) • Ultrasound - pelvic • Cystoscopy

  28. Urinary Obstruction / Hesitancy / Prostatic Cancer Key Objective (s): Determine whether a patient has an acute obstruction any time the complaint is complete anuria or unexplained renal insufficiency

  29. Urinary Obstruction / Hesitancy / Prostatic Cancer Objective (s): Through efficient, focused, data gathering: Determine whether the obstruction is acute or chronic, duration, complete or partial, and unilateral or bilateral, and site. Ask whether pain is present, site of pain (e.g., suprapubic for bladder distention, flank for renal capsule), whether it is colicky and radiates to ipsilateral testicle or labia (renal or ureteral colic), or occurs after a fluid load that increases urine output (e.g., beer drinking). Examine for tenderness, hydronephrosis, hypertension, and palpable bladder. List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis: Select ultrasonography as the diagnostic imaging tool to diagnose obstruction. List indications for other types of diagnostic imaging. Select and interpret tests of renal function; outline indications for prostate cancer screening. Conduct an effective plan of management for a patient with urinary tract obstruction: Perform catheterization of the bladder for both therapeutic and diagnostic reasons. Select patients for referral to specialized care.

  30. Definitions • Uremia = clinical signs and symptoms seen as a result of renal failure • Azotemia = elevation of blood urea (BUN) • Obstructive Uropathy = reversible or irreversible renal dysfunction due to the effects of impaired urine drainage • Hydronephrosis = dilation of the renal pelvis and calyces

  31. Urinary Tract ObstructionClassification • Supravesical vs. Infravesical • Acute vs. Chronic • Unilateral vs. Bilateral • Anatomical site • Intrarenal • Ureter • Bladder • Prostate • Urethra • Extraluminal (LN, mass) vs. Intraluminal (stone, blood clot, fungus ball) vs. Intramural (TCC, polyp)

  32. Diagnosis Clinical features • Flank pain/renal colic • Urinary retention or overflow incontinence • Anuria or oliguria • Uremia • Stones • Recurrent UTI • Asymptomatic

  33. PathophysiologyFactors Influencing Severity of Renal Dysfunction • Complete or partial obstruction • Duration; >30 days of complete obstruction results in irreversible loss of renal function • Unilateral or bilateral • Presence of infection

  34. Urinary Tract ObstructionMajor Sequelae • Loss of renal function • Urinary tract infection / sepsis • Stones

  35. Urinary Tract ObstructionDiagnosis • Clinical features • Laboratory investigations • Imaging studies

  36. Urinary Tract ObstructionDiagnosis • Laboratory investigations • Elevated BUN and Cr with bilateral ureteral or bladder outlet obstruction • Abnormal urinary indices

  37. Urinary Tract ObstructionDiagnosis • Imaging studies • Renal ultrasound • Intravenous pyelogram (IVP) • CT Scan • Retrograde pyelogram • Lasix renogram

  38. Hydronephrosis may not develop if acute obstruction or if presence of perinephric fibrosis

  39. Urinary Tract ObstructionTemporary Measures • Bypass the cause of obstruction • Bladder outlet obstruction • Foley catheter • Renal or ureteral obstruction • Ureteral stent • Nephrostomy tube

  40. Percutaneous Nephrostomy Ureteral Stenting

  41. Urinary Tract ObstructionDefinitive Treatment • Remove the cause of obstruction • BPH • Pharmacotherapy (alpha-blockers) • Surgical (TURP) • Stone • ESWL, ureteroscopy, percutaneous stone removal

  42. Prostate Cancer • Most common solid tumor in U.S. males • Second leading cause of male cancer deaths • Lifetime risk 1/6 • Lifetime risk of a 50 year old: 50%, risk of dying 3% • Risk factors • Family history: 1st degree relative (2x) • blacks • High dietary fat • Histologic Incidence rates • 10-30% > 50 • 50% > 80

  43. Presentation • Asymptomatic • (75%) h PSA • abN DRE • Locally Advanced • LUTS (uncommon without met) • Hematuria • Hematospermia • Renal failure • Metastatic Disease • Bony pain (osteoblastic) • Renal failure • DDx Prostatic Nodule • Prostate Cancer (30%) • BPH • Prostatits • Prostatic Infarct • Prostatic Calculus • Tuberculous Prostatitis

  44. PSA • Enzyme produced by epithelial cells of prostate gland to liquify the ejaculate • Elevated in: • Prostate cancer • Prostatitis • BPH • Trauma • catheterization • Ejaculation

  45. Screening • DRE • Hypothenar eminence = benign • PSA • CCFP - not recommended • US FP + Urologist – recommended • “normal” < 4 but 30% have PCa Age 50 unless 1st degree relative or black male >>>40-45 yrs Screen between ages 50-70/75 years

  46. Screening Probability of Finding Cancer on Biopsy According to a Man’s DRE Result and PSA Level PSA (NG/ML) DRE N AbN

  47. If abN DRE +/ h PSA.. AND > 10 YR LIFE EXPECTANCY… TRUS + BIOPSY

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