Urgent Urologic Disease

00:01 So, let's discuss urgent urologic issues.

00:05 And I'm going to highlight a couple that are important for your exam, but also very pertinent to direct patient care that I do in my practice.

00:13 And the first is going to be kidney stones, nephrolithiasis.

00:17 So, the lifetime prevalence of getting a kidney stone is 10 to 15%.

00:21 This is a really common disorder.

00:23 Good exam question, what's the most common type of stone found by far.

00:28 It's calcium oxalate.

00:30 But you can also see stones made of cystine or struvite if the patient has a history of recurrent urinary tract infection.

00:37 Or uric acid if they have a history of gout.

00:39 And just remember that kidney stones I think to me are the great pretender.

00:44 They can produce a flank pain that radiates down into the groin.

00:48 That’s kind of a classic.

00:50 But they can also present as a vague abdominal pain, an inguinal pain.

00:54 Therefore, they can mimic a bunch of other conditions.

00:56 So, stone is on the differential for a lot of different types of pain and patient problems.

01:03 But the workup is fairly straightforward.

01:05 Get a urinalysis. Of course, looking for blood.

01:08 But do remember that about 10% of cases of nephrolithiasis have a negative urinalysis for blood.

01:16 And that's why we get imaging.

01:18 And an ultrasound can be effective.

01:20 A lot times, I order a CT urogram which doesn't require contrast.

01:25 But both of these tests can help diagnose a patient with nephrolithiasis even regardless of what their urinalysis may show.

01:35 Do understand as well that sometimes the things that we do as physicians can promote stone formation, one of which is treatment with antibiotics.

01:44 So, those are sulfamethoxazole, amoxicillin, quinolones are all associated with a higher risk of stone formation.

01:51 For patients with diabetes, sulfonylureas can promote stones.

01:55 So can potassium-sparing diuretics.

01:57 Might be – use those in cases of heart failure.

02:00 And then laxatives which is, of course, a favorite among some of my older adults, can also be associated with stone formation.

02:06 Just something to keep in mind, particularly after that first stone is passed, maybe worthwhile to think about changing some of these drugs to prevent another stone from forming.

02:16 What do you do with the management of nephrolithiasis? Well, a smaller stone among patients who aren't pregnant, it’s usually just managed by hydration alone.

02:25 So, two liters or more than two liters every 24 hours, along with pain management with opiates.

02:32 Using calcium channel blockers or alpha antagonists may help the stone pass a little bit earlier.

02:38 So, if patients can tolerate that, particularly if they're really uncomfortable, that can be a good idea.

02:43 Not a role for corticosteroids among these patients with small stones.

02:47 And they usually do pass on their own.

02:49 After it's passed, make sure that you check basic metabolic panel.

02:54 You’re really looking for the creatinine and renal function, but really also at levels of potassium, levels of calcium, and make sure those are normal.

03:05 And then, in terms of preventing the next stone for patients, particularly for calcium oxalate stones, you shouldn’t be avoiding calcium.

03:14 Calcium supplements might actually help prevent stone and thiazide diuretics definitely can lower the risk of recurrence because they are actually taking back, within the nephron, calcium and re-absorbing that into the circulation.

03:28 For larger stones, stones that aren’t passing, more complicated stones, really beyond the scope of what we’re going to discuss today, but requires urological management.

03:37 So, you need a specialist on-board.

03:41 For prostatitis, this is a picture of the prostate.

03:44 Normal on the left, enlarged on the right, and that can be due to infection, but you could see just the scope of how big that gland can get.

03:52 It has a lot of room to grow.

03:54 And, obviously, when it does, it’s going to cause obstructive urinary symptoms.

03:58 And prostatitis is different from benign prostatic hypertrophy.

04:04 And it often is associated with pain as well.

04:07 So, I think the keys to understanding prostatitis, both for your knowledge and for the exam, is there are two prevalence peaks.

04:14 One during young adulthood and one during older age.

04:18 That said, E. coli is the most common organism.

04:21 But you see other organisms that are commonly implicated in urinary tract infection, also involved in causing prostatitis.

04:29 And this is another one that’s kind of hard to pin down because the pain is very difficult for patients to describe.

04:39 It's usually more dull, but then it can become sharp.

04:42 And the location is really tricky.

04:44 So, think about pain in any of those areas – superpubic, rectal, perineal can all represent prostatitis.

04:51 When you do the exam, this is one of the exams where a digital rectal examination is necessary.

04:57 I don't believe in the digital rectal examination for asymptomatic patients.

05:01 Doesn't really have the sensitivity to detect prostate cancer or colorectal cancer.

05:06 But if you have a patient with potential prostatitis, they absolutely need to have their prostate checked with a DRE.

05:12 But, however, in doing so, avoid vigorous prostate massage.

05:16 That can actually seed the bloodstream and therefore promote sepsis, so a really bad idea.

05:22 Just remember that the – even though the infection that may be there in the prostate doesn’t necessarily spread into the urine if it’s localized.

05:31 So, in about a third of cases, the urine culture is going to be negative.

05:35 And also, I'm pretty liberal in testing my patients for sexually transmitted diseases.

05:41 It's classically among patients who are a little bit younger, but people have sex their whole lives it turns out.

05:47 So, therefore, I'm always thinking, it doesn't hurt to get a culture or a DNA specimen for gonorrhea and chlamydia as well.

05:58 So, just to – again, a demonstration that the prostate can be large.

06:02 It looks painful from here.

06:04 Now, how do you treat it? For outpatients, usually giving a shot of ceftriaxone and doxycycline for 10 days is enough.

06:12 The other option is treat it like a urinary tract infection.

06:15 But again, I think the key difference between prostatitis and most urinary tract infections is the duration of treatment.

06:22 So, if you see that there, we think about – well, we’ll treat a urinary tract infection in a man for seven days.

06:31 For prostatitis, it’s 10 to 14 days because that infection is kept in the prostate.

06:37 It’s harder for the antibiotics to penetrate and, therefore, need more time with the antibiotics.

06:42 For inpatient treatment, don't treat a lot of inpatients for prostatitis.

06:45 But, say, they did develop sepsis related to their prostatitis, they should definitely come in.

06:50 You can still use a quinolone.

06:51 It doesn't – and oral and IV are really equivalent with quinolones.

06:56 But for more severe – some severely ill patients, broad coverage, piperacillin, tazobactam and probably adding in aminoglycoside.

07:05 If they are that sick to come into the hospital and receive piperacillin, tazobactam, I would add aminoglycoside, if I could.

07:13 And then again, think about a longer treatment duration, particularly if they’re really sick.

07:17 You’re going to treat for up to four weeks.

07:22 So, that covers nephrolithiasis and prostatitis, two important conditions that usually respond to therapy.

07:31 But you also can use your help of your urologic colleagues for those cases that break through.

07:37 Thanks.