R. Matthew Smith M.D. Mercy Urology

None Disclosures

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

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

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

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)

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)

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

New Ventures Advanced Prostate Cancer clinic In Office evaluation for Sacral Nerve Stimulation Urodynamics program

Future Growth Men s health clinic ED Testosterone Metabolic Stone clinic Run by NP? Incontinence Center Pelvic floor rehab PTNS Biofeedback

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

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.

Voiding Physiology The bladder has 2 functions Filling (Storage) Emptying

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

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

Voiding Pnemonic Sympathetic nervous system promotes Storage Parasympathetic nervous system promotes Peeing

BPH

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

BPH

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

Trabeculations

Cellules

Divertiucla

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)

BPH Danger signs Early Urologic Referral Recurrent / Persistent urinary retention Recurrent UTI Recurrent / Persistent gross hematuria Recurrent / large bladder stones Hydronephrosis or renal insufficiency

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

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

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

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

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)

Flow effects 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)

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

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

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.

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

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%

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

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

Complicated Stratifying OAB 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

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

Oral Meds - anticholinergics Inhibit muscarinic receptors, which reduce detrusor overacitivty 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

Oral Meds - Anticholinergics Side Effects Dry mouth Constipation Blurry vision Headache Dizziness Drowsiness Rare: Tachycardia, Urinary retention, Cognitive impairment, impaired perspiration

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)

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

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)

Refractory/Complicated OAB Further workup PVR Voiding Diary Cytology Renal U/S Cystoscopy Urodynamics

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

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

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, Nonobstructive urinary retention. Efficacy: 50% dry 60-90% improved

Interstim Contraindications Need for MRI Previous damage to sacral nerves

Hematuria Get a microscopic urine Prostate Cancer Review 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

Future Topics -??? Erectile Dysfunction Bladder Pain Syndrome / Interstitial Cystitis Premature Ejaculation... You tell me....

Thank You