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R. Matthew Smith M.D. Mercy Urology
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Disclosures
None
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Goals
Update growth of Mercy Urology Clinic Quick Review of Hematuria and PSA Present common urologic complaints seen
by the primary care physician BPH OAB / Urge Incontinence
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Mercy Urology
Started seeing patients 9/6/2016 Current complement: Physician: One full time (Me), weekend locum coverage Jerry Murphy 5/2017 Nathalie Francois starting 8/2017
Mid Levels NP Identified, starting in 1-2 weeks
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What are we seeing
Cancer Prostate Bladder Kidney Testicular
Voiding Dysfunction: BPH overactive bladder/urgency/urge incontinence incontinence
Infection: Chronic UTI Reproduction: Vasectomy Peds: Circumcision, bed wetting, reflux
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Our number so far . . .
September through January New Patients: 516 (410)
Sep: 61 (51) Oct: 125 (77) Nov: 138 (98) Dec: 98 (90) Jan: 94 (94)
Procedures: 158 Sep: 2 (2) Oct: 26 (23) Nov: 35 (31) Dec: 39 (39) Jan: 46(46)
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OR
Surgery Total: 158
Sep: 18 Oct: 32 Nov: 53 Dec: 55 Jan: 55
What are we doing Cysto / Stent: 23 Ureteroscopy / laser: 31 Bladder tumor: 15 Davinci : 2 (prostatectomy / nephrectomy)
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From Idle to Full throttle
We are busy Ramp up of clinic faster than expected Booking into April . . .
Struggles Access Adding NP to take acute patients and returns
How can you help If you have someone that needs to be seen – let me know
Inbox, text, call If you have someone that has a non-urgent problem . . .
Consider holding referral for a few months
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New Ventures
Advanced Prostate Cancer clinic In Office evaluation for Sacral Nerve
Stimulation Urodynamics program
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Future Growth
Men’s health clinic ED Testosterone
Metabolic Stone clinic Run by NP?
Incontinence Center Pelvic floor rehab PTNS Biofeedback
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Hematuria Review
Seeing increased ordering of upper tract imaging prior to urologic evaluation
We are performing more same day cystoscopy (at time of hematuria NP visit)
Some things to remember: Any (Most?) Gross Hematuria gets workup For microhematuria: MUST have a micro. MUST have 3
or more RBC per HPF Dip doesn’t count. Importance of getting micro at time of dip
UA order – dip with reflex to micro
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Prostate Cancer The importance of the DRE/PSA
Case Studies . . . . RG: 65M, otherwise healthy, micro hematuria. PSA 0.9
Distinct small nodule on PSA . . . Gleason 9 cancer EB: 81M, prostatectomy 2001. PSA negligible x 10 years
Referral for GH. DRE: HARD right rectal mass. Workup: PSA 15, right hydro, large R pelvic mass
4+4=8 recurrent prostate cancer DH: 68M, Initial screening PSA 1300, DRE: Bilateral nodules
Extensive metastatic disease JM: 81M for voiding trial. DRE: extensive nodules
PSA: 70, Extensive local disease.
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Voiding Physiology
The bladder has 2 functions Filling (Storage) Emptying
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Voiding Physiology
Filling phase Absence of involuntary contractions Accommodation
Compliance – viscoelastic properties of the bladder Neurogenic bladder: poor compliance – high pressures –
dangerous! Sympathetic stimulation relaxes bladder Parasympathetic inhibition relaxes bladder
Closed bladder outlet Sympathetic stimulation
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Voiding physiology
Normal Emptying Absence of obstruction (BPH, stricture, etc) Open bladder outlet
SNS inhibition – decreases involuntary sphincter tone Onuf’s nucleus (somatic) inhibition – decreases voluntary
tone
Coordinated detrusor contraction PNS STIMULATION SNS INHIBITION
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Voiding Pnemonic
Sympathetic nervous system promotes Storage
Parasympathetic nervous system promotes Peeing
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BPH
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BPH Occurs in the transition zone As men age, Increase in prostate stroma tissue
Growth into the lumen – obstruction of flow Growth mediated by 5-alpha-reductase
Increase in # of alpha-1 receptors Increase in smooth muscle tone
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BPH
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Lower Urinary tract symptoms
Obstructive Symptoms Decreased force of stream, hesitancy, intermittancy, post void
dribbling Irritative symptoms
Urgency, Frequency, Nocturia Bladder outlet obstruction from BPH
Increased smooth muscle tone Prostate growth into lumen of prostate Degree of obstruction does not correlate with severity of
symptoms Definitive test for BOO is urodynamics
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Trabeculations
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Cellules
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Divertiucla
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Evaluation and Tx of BPH
History and Physical **** Includes DRE
Assess severity and bother Formal or Informal (IPSS)
Frequency / Volume chart Post Void Residual (EUA not AUA guideline) PSA (Diagnostic, not screening) UA (Diagnostic, not screening)
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Evaluation and Tx of BPH
History and Physical **** Includes DRE
Assess severity and bother Formal or Informal (IPSS)
Frequency / Volume chart Post Void Residual (EUA not AUA guideline)
PSA (Diagnostic, not screening) UA (Diagnostic, not screening)
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BPH Danger signs Early Urologic Referral
Recurrent / Persistent urinary retention Recurrent UTI Recurrent / Persistent gross hematuria Recurrent / large bladder stones Hydronephrosis or renal insufficiency
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Evaluation and Tx of BPH
If no danger signs, assess bother No bother – Surveillance Bother Non invasive Tx or meds Obtain voiding diary Polyuria – polyuria eval
Persistent / worsening disease Advanced eval with urology
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Assessing for BOO
PVR Measurement Scanner or catheter
Uroflow Max, average flow; flow time; flow curve
Cystoscopy Trabeculations / cellules / Diverticula
Urodynamics – low flow with high detrusor pressure
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Non Invasive Treatment
Alter Non BPH factors Avoid substances that promote retention
Alpha agonists (pseudophed) Anticholinergic or B3 agonist
. . . . But we often use them for LUTS management Caffeine, spicy food, alcohol – may decrease OAB symptoms
Nocturia Decreased fluid intake Avoid night time diuretics
Surveillance Repeat evaluation every year
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Phytotherapy
Not recommended by AUA Efficacy data are lacking ? Some men may benefit
Commonly used substances Saw Palmetto (Serenoa repens) African Plum Stinging nettle Pumpkin seed African Star grass Rye grass pollen
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Alpha blockers
Inhibit alpha-1 adrenergic receptors, relaxing smooth muscles in prostate and bladder neck
Prostate has alpha-1-A receptor Alpha-1-B in blood vessels Alpha-1-D in nasal passages – congestion
Non-selective alpha blockers Terazosin (Hytrin), doxazosin (cardura),
alfuzosin(uroxatal) Selective Alpha blockers
Tamsulosin (flomax), sildosin (Rapaflo)
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Effects Flow effects
Usually occurs within 8 hours for alpha-1-A selective 2-4 weeks for non selective
Symptom effects Begin in 1-3 days, may take several months to reach
maximum effect Side Effects
Dizziness, fatigue, nasal congestion, orthostatic hypotension (uncommon), syncope (rare) Retrograde ejaculation (28% sildosin, 18% tamsulosin)
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Intraoperative Floppy Iris Syndrome
Any prior use of alpha blockers put a patient at risk of intraoperative floppy iris syndrome during cataract surgery Ophthalmology needs to know prior to procedure
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5-alpha-reductase inhibitors
Finasteride (proscar), and Dutasteride(Avodart) Blocks conversion of Testosterone to Di-Hydro-
Testosterone Reduces prostate volume by 20-25% Increases flow by 10% Improves symptom score by 25% Decreases episodes of acute retention by 50% Decreases PSA by 50% (9-12 months) Decreases chronic hematuria from prostate
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5-alpha-reductase inhibitors
Finasteride (proscar), and Dutasteride(Avodart) Blocks conversion of Testosterone to Di-Hydro-
Testosterone Reduces prostate volume by 20-25% Increases flow by 10% Improves symptom score by 25% Decreases episodes of acute retention by 50% Decreases PSA by 50% (9-12 months) Decreases chronic hematuria from prostate
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5AR Side Effects
Impotence (<5%) Decreased libido (<4%) Decreased volume of ejaculate (<3%) Gynecomastia (<1%) Does finasteride increase risk of high grade prostate
cancer? Probably not – Increase in incidence likely due to
increased yield.
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Tadalifil
Used for Erectile dysfunction and BPH Improves max flow rate Comparable to tamsulosin for decreasing symptoms
from BPH Other PDE-5 not approved (short half life; prn dosing)
Tadalafil is long half life, can be given daily
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Combination Tx MTOPS / CombAT trials
Alpha blocker and finasteride/dutasteride Combination therapy is better than either agent alone
Progression of BPH Monotherapy ~ 60% Dual thearpy ~ 35%
Prevention of acute retention Monotherapy (5ARI) – 68% Dual therapy – 81%
Reduction in need for surgery Monotherapy (5ARI) – 64% Dual therapy – 67%
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BPH and Overactive Bladder
BOO from BPH may cause over-activity Secondary effect on bladder
OAB may occur in absence of BOO See next section
No OAB meds are approved for BPH I use them in men with Primarily irritative symptoms
and low PVR
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OAB / Urge Incontinence
OAB – clinical diagnosis “urinary urgency, usually accompanied by frequency and
nocturia, with or without urge incontinence, in the absence of a urinary tract infection or other obvious pathology”
Risk factors Age Chronic obstruction (BPH) Pregnancy Vaginal delivery Postmenopausal status CNS disorders (stroke, SCI, etc)
Most common cause: idiopathic
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Stratifying OAB Complicated
Severe symptoms Young age Gross Hematuria Recurrent UTI Significant Pelvic Organ Prolapse Fecal Incontinence Constipation Hx of pelvic cancer, pelvic/vaginal surgery, radiation Neurologic disease Impaired mobility Poorly controlled DM
Uncomplicated None of the above
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Workup/Tx for uncomplicated OAB
Workup History / Physical, Urinalysis
Assess bother Behavioral Therapy
Timed voiding (q2hrs while awake) Fluid Management Avoid bladder irritants (caffeine, spicy foods, etc) Avoid constipation Weight loss Smoking Cessation Pelvic floor therapy (Kegals) – Hold 6-8 secs, relax. X10, TID
Oral Meds
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Oral Meds - anticholinergics
Inhibit muscarinic receptors, which reduce detrusor over-acitivty
All anticholinergics have similar efficacy Improved efficacy if combined with Pelvic floor muscle
therapy Initial Improvement in 1 week, may take up to 3 months Contraindications:
Urinary retention Gastric retention – concurrent K theraphy Intestinal obstruction Uncontrolled narrow angle glaucoma Myasthenia Gravis
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Oral Meds - Anticholinergics
Side Effects Dry mouth Constipation Blurry vision Headache Dizziness Drowsiness Rare: Tachycardia, Urinary retention, Cognitive
impairment, impaired perspiration
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Anticholinergic Meds
Oxybutynin (Ditropan) Short acting / long acting. Highest rate of dry mouth/ constipation / cognitive
impairment Tolteridine (Detrol) Darifenacin (Enablex) Solifenacin (Vesicare) Fesoteridine (Toviaz) Trospium (Sanctura) – least effect on CNS (quaternary
amine)
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How do I pick an anti-cholinergic?
Side Effects Try not to use Immediate release oxybutynin Sanctura for elderly
Cost Whatever their insurance will pay for ‘Don’t let them touch it’
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B3 agonist - Mirabegron
Actively relaxes detrusor muscle Bladder contains all 3 Beta receptors
B3 most abundant B1 – increase HR, BP (kidney – renin; vascular –
contraction) Mirabegron has low affinity for B1/B2 Start to see effects at 4 weeks, may take 8-12 for full effect SE: Increased BP (10% - don’t give in uncontrolled HTN,
monitor), Headache (3-4%), Nasopharyngitis (3-4%), Tachycardia (rare), Retention (rare)
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Refractory/Complicated OAB Further workup PVR Voiding Diary Cytology Renal U/S Cystoscopy Urodynamics
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Surgical Tx of OAB
Botox Onabutulinumtoxin-A (OBTA) Inhibits release of acetylcholine from vesicles in the
presynaptic side of the neuromuscular junction. Efficacy
60-75% of pts see improvement of 50% or more 30-40% see complete resolution
Duration: 3-12 months SE:
UTI Urinary retention (must be willing to self cath) Systemic spread is rare
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Percutaneous Tibial Nerve Stimulation
Percutaneous needle electrode stimulates Tibial Nerve (S3 root)
Leads to modification of voiding reflex Treatment course
30 min weekly x 12 weeks Customized maintenance schedule
Efficacy: Significant improvement in 60% of patients. Contraindications: Pasemaker/Defibrillator,
coagulopathy, pregnancy
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Sacral Nerve Stimulation (Interstim)
Modifies voiding reflex by stimulating S3 afferent nerve 2 stage process
In office or OR test If test shows improvement, implantation of permanent
generator Indications: Failure of conservative Tx for OAB, Urge
Urinary Incontinence, urgency, frequency, Non-obstructive urinary retention.
Efficacy: 50% dry 60-90% improved
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Interstim
Contraindications Need for MRI Previous damage to sacral nerves
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Review Hematuria
Get a microscopic urine
Prostate Cancer DRE, strongly consider PSA
BPH Alpha blockers/5ARI are mainstays of treatment Look for danger signs
OAB Uncomplicated/mildly complicated
treat with anti-cholinergics / mirabegron
Complicated or refractory: Urology referral
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Future Topics - ???
Erectile Dysfunction Bladder Pain Syndrome / Interstitial Cystitis Premature Ejaculation . . . You tell me . . . .
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Thank You