Urology/Nephrology

Lecture Two – Monday, February 25

Nephrolithiasis / Urolithiasis

Nephrolithiasis/Urolithiasis• http://ww

w.youtube.com/watch?v=NlLix1fHj50

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)

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

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

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

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

Benign Prostatic Hyperplasia

Benign Prostatic Hyperplasia• Most common

benign tumor in men – age related

• Clinically evident disease is less common

• Genetic• Possible racial

component

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

Benign Prostatic Hyperplasia

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

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

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

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, Pygeum africanum bark,

Echinacea purpurea root, Hypoxis rooperi 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

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 (hypervolemic hyponatremic 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

BPH Treatment—TURP

BPH Treatment—Open Prostatectomy

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

Erectile Dysfunction

Erectile Dysfunction

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

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

Erectile Dysfunction

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

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

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

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

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

Testicular Torsion

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

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.

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

Questions?