Common Urology. RMH Grand Rounds Feb Greg Harrington h9p://rmurology.com/

Transcription

1 Common Urology RMH Grand Rounds Feb Greg Harrington h9p://rmurology.com/

2 Disclosures Nil ObjecGves review and discuss common urologic condigons Competencies diagnose and treat common urologic condigons - When to refer

3 Urologic Emergencies Acute Urinary Reten.on Tes.cular Torsion Priapism Paraphimosis Fournier s Gangrene Obstructed kidney with sepsis Trauma

4 Diagnosis?

5 Diagnosis?

6 Diagnosis?

7 Diagnosis?

8 Tes5s Torsion

9 Acute Scrotum

10 Acute scrotum algorithm

11 Pathogenesis of priapism MEDICATIONS NEUROLOGIC OTHER An.hypertensives Hydralazine CCBs Psychiatric Trazadone Chlorpromazine Thioridazine Erec.le Dysfunc.on Sildenafil/ valdenafil Recrea.onal drugs Alcohol Cocaine Spinal stenosis Spinal cord lesions or trauma MulGple sclerosis Spider bites Carbon monoxide poisoning Total parenteral nutrigon (TPN) Blood dyscrasias

12 Diagnoses? A B C

13 Ques5on -Detrusor hyper-reflexia in the female a. is best treated by colposuspension b. is not helped by angcholinergic drugs c. is associated with unstable bladder contracgons d. rarely causes urge incongnence e. is best managed by cystectomy

14 OAB

15 Behavioral interven5ons Pelvic floor muscle exercises. Kegel exercises strengthen pelvic floor muscles and urinary sphincter. It may take 8-10 weeks to nogce a difference in symptoms Healthy weight -weight loss ease symptoms. More so with stress urinary incongnence Fluid consump.on - RestricGng type, volume and Gming may help Double voiding Scheduled toile.ng IntermiOent catheteriza.on Absorbent pads Bladder training - Bladder training to delay voiding when urge to urinate

16 Medica5ons AnGcholinergic/anGmuscarinics -relax the detrusor muscle can be helpful for relieving symptoms Tolterodine (Detrol) Oxybutynin (Ditropan) only Pharmacare approved drug Oxybutynin as a skin patch (Oxytrol) Oxybutynin gel (Gelnique) Trospium (Sanctura) Solifenacin (Vesicare) Darifenacin (Enablex) Mirabegron (Myrbetriq) Fesoterodine (Toviaz)

17 Invasive Op5ons Bladder injec.ons OnabotulinumtoxinA Botox - injected into bladder Gssues, this protein pargally paralyzes muscles. Clinical research shows that it may be useful for severe urge incongnence. The effects are temporary, lasgng only about six to nine months. Can contribute to atonic bladder - willing and able to catheterize if urinary retengon occurs. Nerve s.mula.on RegulaGng the nerve impulses to bladder Surgery Intractable & severe symptoms failing other treatments. The goal is to improve the bladder's storing ability and reduce pressure in the bladder. WILL NOT help relieve bladder pain. Surgery to increase bladder capacity by augmentagon with bowel segments Bladder removal - last resort

18 Incon5nence classifica5on

19 PSA controversy Recommenda.ons for PSA Tes.ng ASCO developed the following recommendagons for PSA tesgng in men with no symptoms of the disease: For men expected to live 10 years or less, general screening is not recommended because the risks appear to outweigh the benefits for most men. For men expected to live longer than 10 years, pagents should talk about PSA tesgng with their doctors to find out if it is an appropriate test for them

20 Let s be more helpful PSA will detect >90% CaP Untreated CaP 90% fatal by 10 years Localized & TREATED CaP 90% alive NED at 10 years Low volume, low Gleason score CaP may progress slowly enough that acgve surveillance is an opgon could be up to 60% T1c, 1-2 cores Gleason 3+3 = 6/10 can be followed with PSA q 3 months + Annual Bx There is a misconcepgon that prostate cancer is a benign disease Problems: gelng good RCT data, lead Gme bias observagon over Gme is probably only answer

21 BPH vs. CaP? Symptoms?

22 BPH vs. CaP Symptoms A need to urinate frequently, especially at night. Difficulty stargng urinagon or holding back urine. Weak or interrupted flow of urine. Painful or burning urinagon. Difficulty in having an erecgon. Painful ejaculagon. Blood in urine or semen.

23 LUTS Lower urinary tract symptoms (LUTS) in men have many causes and are ooen mulgfactorial A full assessment helps in making a diagnosis and avoids the assumpgon that LUTS in all men are due to benign prostagc hyperplasia (BPH) Frequency volume charts are underused but ooen provide important diagnosgc clues Lifestyle measures, in pargcular altering fluid intake, can be useful for men with LUTS α blockers are the usual treatment for LUTS due to BPH, and angmuscarinics for overacgve bladder 5 α reductase inhibitors reduce the risk of clinical progression and should be targeted at those at high risk of clinical progression A range of surgical opgons are available for men who fail inigal medical management

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26 LUTS Key points What are you treagng? BPH, OAB, CaP Red Flags High PSA, UTI, Renal insufficiency, Hematuria, RetenGon Tolerable Sx with no flags pagent choice Meds or no meds Bothersome Sx Alpha blocker (tamsulosin ) +/- 5ARI (dutasteride) +/- OAB med RetenGon, recurrent UTI, Renal damage, recurrent hematuria, failed medical Rx indicagons for TURP

27 Green Light Laser TURP potassium-titanyl-phosphate-(ktp) selectively absorbed by Hb and not H20

28 ComplicaGons include: urine infec.on (UTI). The prostate itself can harbour bacteria which is released during the surgery. Hence, it is important to ensure that the urine is sterile before surgery and angbiogcs congnued even aoer the operagon. bloody urine. This can last up to 3 weeks but less compared to standard TURP. Some men may also experience frequent urinagon, urgency and incongnence which can take up to 3 months to subside. dry ejacula.on. This is due to the backward passage of sperm during sexual intercourse. It is inevitable because the bladder neck is also destroyed and the semen preferengally goes into the bladder. OAB irritagon Sx Common but temporary bleeding 10% of cases and appears between the 7th to 10th day aoer surgery. Reten.on. Some pagents may not be able to pass urine aoer the catheter is removed. This is usually due to excess swelling of the remnant prostate. The catheter will need to be re-inserted if this happens. Desired outcomes: no blood transfusion ( < 1% chance ) low UTI rate ( < 5% occurrence ) Day Care with low re-admission for secondary bleeding ( < 1% rate ) All will have WBC +++ on post op U/A C&S needed to Dx UTI Disadvantage no Gssue Dx

29 Circumcision

30 Urethral Stricture

31 Holmium Laser for calculi

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