Urology/Nephrology

1. Urology/Nephrology Lecture Two – Monday, February 25

2. Nephrolithiasis / Urolithiasis

3. Nephrolithiasis/Urolithiasis • http://www.youtube.com/watch?v=NlLix1fHj50

4. Nephrolithiasis / Urolithiasis • Incidence – 3rd most common urinary tract disorder • men to women 2.5:1 • Initial – 3rd-4th decades • in 6th-7th decades men = women • Types of Stones – calcium oxalate, calcium phosphate, struvite, uric acid, cysteine • Contributing factors – high humidity, elevated temperatures, sedentary lifestyle, high protein, high salt, genetics (cystinuria, distal renal tubular acidosis)

5. Signs and Symptoms • colic – usually sharp, severe pain originating in flank and which may radiate down back or over abdomen, may be referred to groin (distal ureter), often intermittent • nausea/vomiting • moving around room • urinary urgency and frequency – if at ureterovesicular junction

6. Diagnosis • Labs – hematuria; r/o infection; pH (normal 5.8-5.9) • Metabolic Analysis – strain urine to catch stone • First uncomplicated stone – serum calcium, electrolytes, uric acid • Recurrent stone or family history – decreased sodium and animal protein intake and increase fluid • 24 hr urine  volume, pH, calcium, uric acid, oxalate, phosphate, sodium and citrate • Labs– KUB or renal US will dx most stones • spiral CT (in prone position) is first-line tool • low density = uric acid, high density = calcium oxalate

8. Treatment • Goal—stone-free status to reduce recurrence • Stones generally recur in 50% of pts in 5 yrs without treatment • greatest importance  increased fluids • sodium <100 mEq/day • animal protein < 1 g/kg/d • bran decreases calcium stones • decrease oxalate and purine • decreased calcium – increased stone occurrence

9. Treatment • Surgical • forced IV fluids will not push stones down—counterproductive and will exacerbate pain • can use alphablocker (tamsulosin 0.4 mg once daily) and NSAID +/- steroid. • If medical expulsive therapy fails after a few weeks or intolerable pain/persistent N/V– ureteroscopic shock therapy or extracorporeal SWL • Ureteroscopic Stone Removal: http://www.youtube.com/watch?v=u9O-kKSxKi0 • Shock Wave Lithotripsy: http://www.youtube.com/watch?v=fR_CjlVXhzw

10. Benign Prostatic Hyperplasia

11. Benign Prostatic Hyperplasia • Most common benign tumor in men – age related • Clinically evident disease is less common • Genetic • Possible racial component

12. Benign Prostatic Hyperplasia • Symptoms– obstructive or irritative • chart page 930—scores index of symptoms for BPH (also at end of handout) • Obstructive – hesitancy, decreased force and caliber of stream, incomplete bladder emptying, double voiding, straining to urinate, postvoid dribbling • Irritative – urgency, frequency, nocturia • Exclude prostate cancer, UTI, neurogenic bladder, urethral stricture • Signs– physical examination, DRE, focused neuro exam • Size and consistency – document, but size does not correlate with degree of obstruction or severity of symptoms • Smooth, firm, elastic enlargement is typical finding • Distended bladder

13. Benign Prostatic Hyperplasia

14. Benign Prostatic Hyperplasia • Labs– urinalysis (r/o UTI, hematuria); PSA (optional) • Imaging– Transabdominal or transrectal prostate US mainly only done if surgical options are being considered • upper tract imaging (CT/renal US) only if concomitant urinary tract disease or complications such as hematuria, UTI, CKD, stones • Cystoscopy– not recommended to determine need for tx • Other tests– urodynamics, cystometrograms • Differential– urethral stricture, bladder neck contracture, bladder stones, UTI, bladder cancer, neurologic bladder, constipation

15. BPH Treatment • Watchful Waiting – mild symptoms (0-7 scores) • some men do not progress or even regress • One study: 10% symptomatic  retention; 50%  improve/regress • Can also monitor patients with moderate/severe disease if they choose

16. BPH Treatment—Medication • -blockers – prazosin, terazosin, doxazosin, tamsulosin, alfuzosin • Side effects include orthostatic hypotension, fatigue, dizziness, rhinitis, headache, retrograde ejaculation • Titrate dosage over a few days (except alfuzosin) • α1a receptors are localized to prostate and bladder neck – fewer side effects (tamsulosin, sildosin) • 5-reductase inhibitors –finasteride, dutasteride • Reduce size of prostate gland – 6 months to max effect (20%) • Symptomatic improvement only in men with enlarged prostates (>40 mL on US) – and PSA 50% lower in pts on finasteride • Side effects include decreased libido, decreased volume of ejaculate, and ED • Incidental 25% risk reduction in prostate cancer but not recommended by FDA for this purpose

17. BPH Treatment—Medication • Combination – both an -blocker and a 5-reductase inhibitor • long term combination therapy with doxazosin and finasteride reduced risk of overall BPH progression significantly more than either drug alone • risks of additional SE and cost • Phytotherapy– Saw Palmetto, Pygeumafricanum bark, Echinacea purpurea root, Hypoxisrooperi root, pollen extract, trembling poplar leaves • Exact MOA unknown • 2006 study—no improvement in symptoms, urinary flow rate, QoL for BPH patients with saw palmetto vs. placebo • Phosphodiesterase inhibitors – taldalafil (Cialis) • New addition to therapy options for BPH • cannot be used in combination with alpha blockers

19. BPH Treatment—Conventional Surgery • TURP – 95% can be endoscopic • retrograde ejaculation (75%), ED (5-10%), incontinence (<1%) • complications include bleeding, urethral stricture or bladder neck contracture, perforation of prostate capsule, transurethral resection syndrome (hypervolemichyponatremic state) • http://www.youtube.com/watch?v=tcUaAXVd4Hg • TUIP – moderate-severe symptoms and small prostates often w/ “elevated bladder neck” • more rapid and less morbid than TURP • similar outcomes except 5% retrograde ejaculation • Open Simple Prostatectomy – large prostate that cannot be removed endoscopically – open enucleation – >100 g • http://www.youtube.com/watch?v=mpvhz1BOcmM

20. BPH Treatment—TURP

21. BPH Treatment—Open Prostatectomy

22. BPH Treatment—Minimally Invasive • Laser –TULIP, PVP, interstitial • minimal blood loss, rare transurethral resection syndrome, outpatient • no pathology, irritative, expensive • TUNA – radiofrequencies heat prostatic tissue causing necrosis • Electrovaporization– heat vaporization causing cavity in prostatic urethra. Takes longer than a standard TURP. • Hyperthermia– via microwave and transurethral catheter

23. Erectile Dysfunction

24. Erectile Dysfunction

25. Erectile Dysfunction • Consistent inability to attain or maintain a sufficiently rigid erection for sexual performance • usually organic, may be psychogenic • 52% of men aged 40-70 years experience ED • Needs intact neurovascular structure with autonomic and somatic nerve supply, smooth and striated musculature, and arterial blood flow

26. Erectile Dysfunction • Signs and Symptoms– detailed history is important! • Severity, Comorbidities, Substance use, Pelvic trauma, Surgery or local irradiation • Loss of libido – androgen deficiency (hypothalamic, pituitary, or testicular) • Loss of erections – vascular, neurogenic, psychogenic • Normal erections at times – unlikely to be biological cause • Attain but not maintain – endothelial dysfunction • Peyronie’s Disease - fibrotic disorder of tunica albuginea resulting in varying degrees of penile curvature and sexual dysfunction • 5% of men >50 years old • without tx 10% improve spontaneously, 45% progress, 45% stabilize • Unclear etiology, multifactorial • subtle trauma followed by abnormal wound healing is a possible cause

27. Erectile Dysfunction

28. Erectile Dysfunction • Priapism – Erection unrelated to sexual stimulation, lasting longer than 4 hours, and potentially leading to irreversible damage to erectile tissues • unregulated high blood flow or trapping of blood • causing ischemia and infarction • ED treatment, drug use, RBC dyscrasia • Loss of seminal emission – anejaculation • androgen deficiency (decreased prostate and seminal vesicle emissions) • sympathetic denervation (DM, surgery) • Retrograde ejaculation – mechanical disruption of bladder neck (TURP), radiation, α-blockers, sympathetic denervation • Loss of orgasm –if erection and libido are intact, usually psychological • Premature ejaculation – persistent or recurrent ejaculation with minimal stimulation before a person desires, associated with distress • Primary – psychogenic (new partner, emotional disorder) • Secondary – erectile dysfunction – may resolve with erectile dysfunction treatment

29. Erectile Dysfunction • Labs – CBC, lipid, FBG, testosterone, prolactin • Abnormal testosterone or prolactin – FSH, LH • Special tests – based on goals and hx when etiology unclear • nocturnal penile tumescence • injection of vasoactive medication • duplex US • cavernosongraphy • arteriography

30. Erectile Dysfunction • Labs – CBC, lipid FBG, testosterone, prolactin • Abnormal testosterone or prolactin – FSH, LH • Special tests – based on goals and hx when etiology unclear • nocturnal penile tumescence • injection of vasoactive medication • duplex US • cavernosongraphy • arteriography

31. Erectile Dysfunction Treatment • Psychoactive – behaviorally oriented sex therapy • Hormonal Replacement – testosterone • hypogonadism, normal PSA and DRE • testosterone does not increase prostate CA risk but does increase PSA • Vasoactive Therapy – oral agents (sildenafil, vardenafil, tadalafil) – inhibit PDE5 and allow cGMP to operate unopposed to stimulate blood flow. Similar efficacy but some pts who do not respond to one may respond to another. • Start at low dose and titrate to effect • No effect on libido, priapism is very rare • Contraindicated in pts on NTG or nitrates • Caution with α-blockers – increased drop in BP • Injectable agents– injection of vasoactive prostaglandins to lateral base of penis, or vasoactive urethral suppository

32. Erectile Dysfunction Treatment • Vacuum Erection Device – creates vacuum chamber around the penis, drawing blood into corpora cavernosa, then elastic band placed proximally to prevent loss of blood and device is removed. • Few complications but cumbersome to use • Penile Prosthesis –implanted into corporal bodies – semi-rigid, malleable, inflatable • Vascular Reconstruction – endarterectomy, balloon dilation, arterial bypass; vein ligation • limited experience • Peyronie Disease – pentoxifylline, colchicine, potassium aminobenzoate, L-carnitine; intraplaque injection of verapamil; surgery

34. Testicular Torsion

35. Testicular Torsion • Rotation of testicle on spermatic cord • Compromise of blood supply • Most common in infants, teenagers and young men, but can occur at any age

36. Testicular Torsion • Causes– genetic predisposition, trauma, exercise, unknown • Bell-and-Clapper Deformity - tunica vaginalis has an abnormally high insertion on the spermatic cord • leaves the testis free to rotate within the tunica vaginalis • deformity is bilateral in most cases.

37. Testicular Torsion • Symptoms – sudden onset of severe testicular pain (may be intermittent), scrotal swelling, nausea, vomiting, light-headedness, abdominal pain • One testicle may be higher or at an odd angle • Tender, swollen testicle • Diagnosis – doppler US of testicle • Treatment – surgical intervention ASAP – if within 6 hours, prognosis is more favorable • Anchoring usually done bilaterally if only one testicle affected as the unaffected testicle is at increased risk for future torsion • Complications– Infertility, testicular damage or death

38. Questions?