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I am 87 years old, with a problem of the prostate gland. Before I met Dr. Baum, I went to the bathroom every 30-60 minutes. After Dr. Baum's treatment on my prostate, I go only 5 times per day and only 1 time at night! You turned my life around. I am so very grateful!

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Suggestions for Managing Urologic Conditions in Your Patients and Indications for Urologic Referral

Dr. Neil Baum* in conjunction with:
Dr. Alex Weinstein (Santa Barbara, CA)
And
Dr. Joe Kuntz (San Luis Obispo, CA)

The Kidney
The Bladder
The Prostate
Urethral Disorders
The Penis
The Testicles and Scrotum
Miscellaneous Topics

THE KIDNEY

RENAL MASSES

  • need to distinguish solid vs cystic
  • if simple cyst by US or CT, no further w/u necessary; simple cysts are benign and rarely of clinical significance.
  • if solid or indeterminate by US, need CT
  • solid masses are almost always malignant; complex cysts may be malignant, therefore these patients require referral to a urologist.

RENAL PAIN

  • usually secondary to acute obstruction/distension e.g. due to stone, pyelonephritis, hemorrhage
  • need to distinguish from musculo-skeletal pain-latter usually affected by body position or movement
  • urinanalysis may be helpful as a microscopic hematuria, pyuria, or a positive dipstik test may increase your suspicion of urinary tract obstruction. However, a negative UA does not entirely rule out urinary tract obstruction.
  • if unsure, obtain imaging study (IVP or US)-if normal or demonstrates non-acute process not renal pain and does not require referral to urologist
  • all pts suspected of having a stone require radiologic imaging: IVP is best study; if contraindicated obtain renal ultrasound and KUB
  • many stones will pass spontaneously and therefore don't necessarily require urologic consultation/intervention

GUIDELINES:

Follow-up with Medicine

  1. <6-7mm ureteral stone - pt should be given oral analgesics, urine strainer and told to push PO fluids; he should then be followed with serial KUBs at 2-4 wk intervals; if stone passes or shows signs of progress down ureter, can continue to follow for 1-2 months as long as patients pain is manageable and not accompanied by UTI. Refer to a urologist if these criteria are not met.
  2. If stone passes, send for stone analysis. These pts do not require referral to a urologist. Advise them to increase water intake for future stone prophylaxis.
  3. Metabolic workup - first-time stone formers do not require any metabolic evaluation. Recurrent stone formers may benefit from metabolic w/u. Pt should be stone-free for 4-6 wks prior to initiating evaluation. The evaluation should include: serum electrolytes, BUN, Creatinine, Ca, P, uric acid and 24-hr urine for Na, creatinine, calcium, uric acid, citrate, oxalate, phosphorous, and magnesium. Follow up of these studies should be either with patient's primary care physician or a nephrologist.
  4. Radiolucent stones are most often uric acid stones which are amenable to dissolution therapy by alkalinizing the urine. Treatment options: Polycitra or Urocit K; need to monitor urine pH and keep pH >7.0 ; follow progress with serial renal ultrasound andor intravenous pyelograms. (If stones are large i.e. > 1.0- 1.5 cm will usually take too long to dissolve and these patients should be referred to a urologist).

Indications for Referral a Urologist

  1. Large stones in kidney or ureter unlikely to pass spontaneously (>6-7mm).
  2. Smaller stones in ureter that have not passed over a period of 1-2 months, or sooner if causing recurrent bouts of colic requiring repeated trips to ER
  3. Stones in pregnant women
  4. Obstructive stones accompanied by infection (obstructive pyelonephritis) these pts require prompt urologic intervention

Indications for Hospital Admission

  1. Vomiting with inability to tolerate oral fluids
  2. Pain uncontrolled by oral analgesics
  3. Obstructing stone accompanied by infection requires prompt urologic intervention

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THE BLADDER

BACTERIAL CYSTITIS IN FEMALES

  • very common in females especially in early adulthood and post-menopausal years; in many women, correlate with sexual activity
  • symptoms: frequency, urgency, dysuria, +/- hematuria
  • usually not associated with fever or signs of systemic toxicity; if these are present, pyelonephritis is more likely
  • Treatment:
    1. Isolated or occasional cystitis can be treated empirically based on symptoms and a positive urinanalysis
    2. Best first-line drugs:
      Septra DS BID x 3-7 Days
      Macrobid 100mg BID x 3-7 Days
    3. If patient fails to improve on empiric treatment, need to discontinue drug, obtain a urine culture and sensitivity several days later to determine sensitivity specific treatment.
    4. If pt has more than 2 UTIs/yr., obtaining a urine culture prior to empiric treatment is important. This not only guides appropriate treatment but also documents true infection and, therefore, earmarks those patients who are candidates for prophylactic treatment and selects out those patients with irritable bladder syndromes, such as interstitial cystitis.
    5. Prophylactic Regimens: recommended for patients with >3-4 culture-proven UTI/year with common gram negative organisms. After treating acute infection, begin low-dose prophylactic antibiotics.


      Best 2 agents: Septra DS or Bactrim DS, q.d. x 4-6 month
      or
      Macrodantin 50mg q.d. for 4-6 months
      (If patients' infections correlate with coitus then can alternatively instruct patient to void after intercourse and take Macrodantin 100 mg or Septra DS within one-hour post-coitus).

      Culture any suspected "break-through" infections

    6. If, after 4-6 months of successful prophylaxis, infections thereafter promptly recur, obtain IVP. If IVP is normal, resume prophylaxis for another 6 months, or for as long as necessary to keep infection rate at <2-3 UTI/year.
    7. Pyridium, 100mg TID or Pyridium Plus, 200mg TID may be used for symptomatic relief awaiting response to antibiotics. It does not however replace antibiotics.
REFER TO UROLOGY
Patients with documented recurrent UTI despite prophylaxis
Patients with significant abnormalities on IVP
Patients with recurrent UTI with less common organisms (e.g. Proteus,
Kliebsella, Pseudomonas); obtain IVP prior to referral.

NONBACTERIAL CYSTITIS IN FEMALES (Irritable Bladder Syndromes)

These patients have symptoms similar to and often mistaken for bacterial cystitis. The patients complain of frequency, urgency, andor urge incontinence and nocturia; there is a spectrum of severity ranging from annoying to almost debilitating symptoms. The hallmark for this diagnosis is irritable symptoms and a negative urinanalysis.

Specific Syndromes:

  1. Overactive Bladder
    "frequency/urgency" syndrome; mild end of spectrum can be exacerbated by stress, caffeine, alcohol or nicotine. Urinalysis must be negative
    Rx:
    1. reassurance (benign, albeit chronic disorder)
    2. behavior modification (decrease fluid intake if excessive, decrease caffeine, alcohol or nicotine and start timed voiding if indicated)
    3. Anticholinergics:
      Ditropan XL, 5,10,15mgday
      Detrol LA, 4mgday
      Urispas 100-200mg TID-QID
      Levsinex BID-TID
  2. Urethritis
    • true urethritis represents only a small percent of patients with irritable
    • voiding symptoms
    • pyuria on initial voided UA
    • urethral tenderness on exam
    • Treatment doxycycline 100mg BID x 7Days
  3. Atrophic Urethritis/Vaginitis
    • can produce irritable voiding symptoms in post-menopausal women
    • note atrophic changes on external genital exam, easily identified by lack of rugae of the vaginal mucosa
    • Treatment: topical premarin
  4. Carcinoma in Situ
    • usually seen in middle-older aged smokers or former smokers
    • irritable bladder symptoms accompanied by hematuria
    • (micro or gross)
    • obtain first morning voided urine for cytology; if suspicious refer to a urologist for cystoscopy
  5. Interstitial Cystitis (IC)
    • extreme end of spectrum
    • symptoms: severe frequency, urgency and typically suprapubic pain that is relieved with voiding
    • patients may also complain of dyspareunia
    • diagnosis of exclusion: UA, urine cultures must be negative
    • if indicated, urine cytology should be obtained
    • final diagnostic step is a cystoscopy under anesthesia combined with hydrodistension of the bladder andor bladder biopsies; IC pts demonstrate characteristic findings in the bladder in response to hydrodistension.
    • Rx: hydrodistension, Elmiron 100mg TID Intravesical instillation of various medications such as DMSO

BACTERIAL CYSTITIS IN MALES

  • symptoms are same as in female however significance is greater young, healthy men rarely get cystitis without underlying anatomic abnormalities therefore evaluation of urinary tract with IVP and in select cases VCUG is indicated- in elderly male population (and at times in younger men) prostatitis can be the underlying etiology
  • in older men with BPH large residual urine can predispose to cystitis
  • UA and urine cultures should be obtained in all patients
  • treatment is same as in female patients with particular emphasis on antibiotics that have good penetration into prostatic tissue in case that is the source of the infection. Good first-line antibiotics are therefore Septra or Tetracyclines; quinolones are excellent second line drugs.

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THE PROSTATE

BENIGN PROSTATIC HYPERPLASIA (BPH)
General Information

  • Occurs in aging males; usually after age 50
  • Symptoms consist of hesitancy, decrease force and caliber of the urianry stream, sense of incomplete bladder emptying, frequency, nocturia, possible urgency with occasionally urge incontinence
  • The symptoms are often worse at night and early in the morning
  • The size of prostate gland estimated on the digital rectal examination does not necessarily correlate with severity of the symptoms
  • Mediations such as decongestants or other sympathomimetic drugs will often exacerbate symptoms and can precipitate acute urinary retention

Treatment

  • Decision to treat is usually based on extent of patient's symptoms and degree to which they are interfering with his lifestyle Mild to moderate obstructive symptoms in patients with small prostate glands will often respond to medical management with alpha-blockers:
    Hytrin 2-5 mgday
    Cardura 2-4 mgday
    Flomax 0.4mgday
  • Patients with large prostate gland and significant symptoms are candidates for 5-alph-reducatase inhibitors, Proscar, 5mgday.
  • Transurethral resection of the prostate (TURP) is indicated in patients who fail or can't tolerate alpha-blockers and for whom the symptoms are significantly interfering with sleep, comfort, and lifestyle.
  • TURP is the procedure of choice in patients who develop severe signs of bladder outlet obstruction including recurring urinary retention or infection, deteriorating renal function, bladder calculi or recurrent gross hematuria from prostatic bleeding.
  • Many alternatives or minimally invasive procedure to these standard forms of therapy are being investigated:
    ongoing investigations for the use of laser prostatectomy, hyperthermia and cryosurgery are being conducted, i.e., TUNA or transurethral needle ablation of the prostate

Referral to a Urologist

  • Patients who are candidates for TURP i.e. whose symptoms are bothersome enough to desire surgery and who have failed or declined medical management
  • Patients with PSA >4.0ngml
  • Patients with abnormal digital rectal exam, i.e., prostate nodule, asymmetry of the prostate gland, or induration of the prostate gland
  • Patients with uninfected hematuria
  • Patients with recurrent UTIs
  • Patients with deteriorating renal function who may have post-renal obstruction, i.e., hydronephrosis
  • The mere finding of an enlarged prostate on DRE and the presence of mild to moderate obstructive voiding symptoms that are not bothersome to the patient do not necessitate referral

CARCINOMA OF THE PROSTATE
General Information

  • most common malignancy in males (excluding skin cancer), more than 250,000 new cases detected each year
  • second leading cause of cancer deaths in males, nearly 40,000year
  • however, only a small percentage of patients with prostate cancer die of the disease;
    30-50% of men over 50 have microscopic disease;
    8% have clinical disease;
    3% die of disease

Screening

  • screening for prostate cancer remains controversial; adding PSA to the DRE can double the detection rate; no data is available to date however to prove that this will decrease the mortality of the disease; in the process of screening some patients may receive treatment who don't need it
  • patients can have cancer with a normal PSA; patients with a mildly elevated PSA may not have cancer; > 30% of patients with a PSA over 10 already have extracapsular disease
  • Free and total PSA. The ratio of free or unbound PSA to total PSA or both free and bound PSA is test that is useful for men with PSAs greater than 4.0 and less than 10.0. In the past men with elevated PSA levels who were candidates for treatment had an ultrasound and biopsy. By obtaining a free to total PSA ratio which is greater than 25% in men with BPH and less than 25% in men with prostate cancer, many men can avoid biopsies
  • for now, wide scale screening for prostate cancer with PSA is not being advocated; yearly DRE is still the recommended screening modality at this time; the trend does seem to be toward screening, at least of men between the ages of 50-70, and it may be that PSAD will ultimately be the recommended modality
  • for now though, if patients request PSA for screening they should be informed of the controversy; if they still desire the test it should be ordered

Refer to Urology

  • any patient with a PSA >4 OR a suspicious lesion on digital rectal exam should be referred to a urologist for further evaluation; prior to referring a patient with a suspicious lesion a PSA should be obtained
  • any man with a freetotal PSA ratio less than 25% should be considered for urologic referral and then be advised about a prostate ultrasound and biopsy
  • Patients greater than 79 y/o should NOT be screened for prostate cancer; nor should they be referred for asymptomatic nodules; they generally are not candidates for treatment at that age unless they have symptomatic disease; in those cases they become candidates for hormonal therapy but not curative therapy

PROSTATE INFECTIONS

  1. Bacterial Prostatitis

    Signs and Symptoms of Acute Bacterial Prostatitis

    • Presents with dysuria, frequency, urgency, fever, perineal discomfort, obstructive voiding symptoms possibly even urinary retention
    • Prostate often tender/swollen on digital rectal exam (take care not to perform rigorous rectal exam on these patients as you may precipitate septcemia)
    • UA and urine cultures almost always positive.

    Signs and Symptoms of Chronic Bacterial Prostatitis

    • Often asymptomatic, except for periodic flare-ups of acute prostatitis or cystitis,
    • May also present with mild to moderate frequency, urgency, dysuria, perineal pain or painful ejaculation
    • Midstream urinalysis and urine cultures may be negative
    • Need to obtain post-prostatic massage urine specimen and/or expressed prostatic secretion for microscopic evaluation (these specimens are obtained by massaging prostate and express small amount of prostatic fluid at tip of urethral meatus for microscopic examination looking
    • The diagnosis is confirmed with the findings of >5 WBC/HPF;
    • Alternatively, patient can be asked to void after prostatic massage and that urine can be sent for a urinalysis and urine culture

    Treatment

    • Etiologic organisms are usually gram negative bacilli
    • Many antibiotics do not diffuse well into the prostatic tissue
    • Sulfas, tetracyclines, carbenicillin and quinolones tend to be effective
    • Initial treatment should be for 2-4 weeks
    • If prostatitis recurs within 3-6 months, repeat initial course of treatment, possibly extending it to a 6 week course and consider low dose suppression treatment with Septra DS or Bactrim DS one tablet daily for several months
  2. Prostatodynia or Chronic Abacterial Prostatitis

    Signs and Symptoms

    • Chronic syndrome producing symptoms almost identical to chronic bacterial prostatitis but with normal exam and normal laboratory findings on the urinalysis and a negative urine culture
    • Patients are often very anxious and preoccupied with symptoms
    • Stress, caffeine, alcohol or nicotine may aggravate symptoms
    • Treatment is empiric and nonspecific; this includes anti-anxiety medications, alpha-blockers, sitz baths, and non-steroid anti-inflamatory medications
    • Patient should be reassured that he does not have a dangerous or life-threatening condition
    • Patient should however also be informed that the symptoms tend to be chronic but will often eventually resolve or at least subside to some extent
    • Medications that may provide symptomatic relief include:
      Celebrex 100-200mgday, Vioxx, 25-50mgday or Motrin 400mg po tid
      Alpha-blockers (Flomax, Hytrin, or Cardura)

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URETHRAL DISORDERS

URETHRTTIS

General Information

Symptoms usually consist of marked dysuria or urethral itching and in males more often than females a urethral discharge. Patients may also complain of frequency and urgency

Sexually Transmitted Urethritis

  1. Gonorrheal - usually presents with above symptoms accompanied by thick, yellowish urethral discharge and appearing within 2-10 days after sexual exposure. Stained smear shows intracellular Gram Negative diplococci. Culture for gonorrhea is positive. Treatment: Ceftriaxone 250 mg IM x I
    +
    Doxycycline 100 mg BID x 7days
    or
    Zithromax 1gmday for two days
  2. Nongonococcal - usually chlamydia (50%) or other (10-15%) including ureaplasma, trichomonas, H. Simplex. The discharge in these patients is usually thinner, more scant and usually clear. The recommended treatment for chlamydial or ureaplasma is Doxycycline 100 mg BID x 7days or Zithromax 1gm; for trichomonas treat with Flagyl 2.0 gram single dose or 500 mg BID x 7 days.
    **Always treat exposed sexual partners

Nonsexually Transmitted Urethritis (NSU)

  1. In small percentage of patients urethritis can also be caused by same organisms that cause cystitis; these patients should have positive bacterial cultures of initial voided urine and should have pyuria. Treat with culture-specific antibiotics. Recurrent episodes may reflect underlying pathology e.g. urethral stricture in males or urethral diverticulum in females and these patients need to be referred to a urologist.
  2. Contact sensitivity to soaps, spermicides, detergents clothing dyes or lubricants used during sex may cause noninfectious urethritis. Elimination of chemical irritant should cause symptoms to resolve.
  3. Asymptomatic milky or mucoid urethral discharge during or following a bowel movement represents prostatic fluid expressed into the urethra by increased intrarectal pressure. It is not pathological and no treatment is indicated.

ATROPHIC URETHRITIS

  • symptoms found in postmenopausal women, often similar to infections, with urinary frequency, urgency and dysuria, but usually with negative urinalysis and urine cultures
  • physical findings consist of pale, thin mucosal surfaces of introitus, urethra and vagina with decreased to absent rugae.
  • treatment: topical Premarin cream every other day or oral estrogen replacement therapy

URETHRAL CARUNCLE

  • small, benign, soft, red lesion usually protruding from female urethral meatus in postmenopausal patient
  • usually asymptomatic but can cause pain, bloody spotting or microhematuria
  • requires treatment only if symptomatic; initial treatment includes topical Premarin cream; if that fails, can be surgically excised.

URETHRAL STRICTURE

  • seen almost exclusively in male patients; usually preceding perineal trauma (straddle injury, urethral instrumentation, surgery) or following treatment of gonococcal urethritis
  • symptoms consist of decrease force and caliber of urinary stream, need to strain to void and possibly sense of incomplete bladder emptying; patients may also have frequent UTI
  • congenital or acquired meatal stenosis can be identified on exam by visualizing an abnormally tiny meatal opening
  • male patients suspected of having a urethral stricture should be referred to a urologist
  • true urethral strictures are rare in females; if present, often have a history of radiation or vaginal/urethral surgery. In past however, many girls and women with recurrent cystitis or irritative voiding symptoms were told that they had urethral strictures or urethral stenosis and needed periodic urethral dilation. That diagnosis and the use of urethral dilation to prevent cystitis has been largely abandoned in today's urologic practice. Many patients with irritable bladders, females in particular, complain of straining to void. However, they strain not because of obstruction by a stricture, but rather because they feel the urge to void when there is very little urine in their bladders.

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THE PENIS

CIRCUMCISION

  • Circumcision is rarely necessary for medical reasons
  • One exception is phimosis in the adult which may be a presenting finding in undiagnosed men with diabetes mellitus
  • Severe phimosis, recurring episodes of paraphimosis or balanitis represent the few medical indications when an elective circumcision should be performed
  • Circumcision for personal or cultural reasons is a controversial issue which is usually left to the judgments of the patient, the referring physician or the urologists after evaluation of the patient

GENITAL WARTS

General Information:

  • Papillary or cauliflower-like lesions on the penis, scrotum, urethra or anus caused by a virus, human papilloma virus, and transmissible by direct sexual contact
  • Warts can be difficult to eradicate
  • They may recur unless the virus is destroyed in the deeper layers of the lesion

Treatment

  • Small warts on the genital skin may be treated with topical application of 20% Podophyllum directly to the lesions with a cotton tip applicator
  • Avoid exposure of surrounding normal skin
  • Instruct patient to wash the medication off after 2-4 hours.
  • Desiccation and sloughing of the warts typically will occur within a few days to a week
  • Repeat applications of Podophyllum may be necessary at 1-2 week intervals.
  • Another alternative is Condylox solution.
  • Patients are to apply the Condylox BID for three days, wait for four days, and repeat the treatment cycle
  • Patients with warts on external genitalia skin not responsive to Podophyllum or Condylox can be referred to a urologist
  • Warts at the urethral meatus should be referred directly to a urologist
  • Podophyllum or Condylox should not be used on mucosal surfaces
  • Female genital warts should be referred to a gynecologist; anal warts should be referred to a general surgeon or a colorectal surgeon.

PHIMOSIS

  • Tight or stenotic foreskin which is difficult or impossible to retract
  • May be congenital or acquired from infection or inflammation
  • Also may be the presenting symptom of diabetes mellitus
  • If mild and not complicated by recurring balanitis, obstruction to urinary flow or painful erections, no treatment is necessary
  • If more severe and/or complicated by above factors, refer to a urologist for evaluation for circumcision

PARAPHIMOSIS

Signs and Symptoms

  • Tight or phimotic foreskin which has been retracted proximal to the glans penis and cannot be easily reduced
  • Constriction by the phimotic band can lead to pronounced edema, erythema and pain of the glans penis and foreskin
  • If not recognized and treated promptly secondary infection and necrosis can result
  • Treatment consists of gently squeeze glans and foreskin/distal shaft milking proximally in attempt to relieve as much edema as possible; after this is done, pull foreskin down over glans while pushing glans proximally thus reducing the paraphimosis. This is often very painful and the patient may require sedation and analgesic medication
  • If unable to reduce, refer to a urologist

BALANITIS

  • Acute or chronic infection/inflammation of glans penis and/or prepuce most often caused by yeast infection, with erythematous patches on the glans and prepuce
  • uncircumcised men are more susceptible, especially diabetics
  • treatment: topical antifungal creams
  • prophylaxis: hygienic measures to keep glans and prepuce clean and dry
  • treat female sexual partner if she has yeast vaginitis
  • circumcision may be necessary in recurrent cases

PEYRONIE'S DISEASE (need information for Verapamil and Website)

  • Acquired, idiopathic condition involving the formation of fibrous plaques in the tunica albuginea of the corpora cavemosa
  • Usually presents as curvature of the penis during erection that may or may not be associated with pain; in severe cases the angulation may prevent successful intromission
  • On exam, can palpate plaque usually located on dorsum of penile shaft condition often resolves spontaneously but may take many months to a year or so
  • Due to incidence of spontaneous regression and potential risks of surgery the management tends to be very conservative
  • Potaba (anti-fibrotic agent) can be tried but success is variable and difficult for patient compliance due to large number of pills required and Gl upset in some patients
  • A new medical alternative is the application of Verapamil paste to the penile lesion three times a day may result in softening of the plaque and a decrease in the curvature of the penis. However, this treatment requires 3-6 months before any significant change will take place. You can obtain this medication for your patient by having him contact 1-800-687-9014 or go online at: http://www.pdlabs.net/
  • Surgery (excision of plaque, grafting and