So, let's discuss urgent urologic issues.
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.
And the first is going to be kidney stones, nephrolithiasis.
So, the lifetime prevalence of getting
a kidney stone is 10 to 15%.
This is a really common disorder.
Good exam question,
what's the most common type of stone found by far.
It's calcium oxalate.
But you can also see stones made of cystine
or struvite if the patient has a history
of recurrent urinary tract infection.
Or uric acid if they have a history of gout.
And just remember that kidney stones
I think to me are the great pretender.
They can produce a flank pain
that radiates down into the groin.
That’s kind of a classic.
But they can also present as a vague
abdominal pain, an inguinal pain.
Therefore, they can mimic a
bunch of other conditions.
So, stone is on the differential for a lot of
different types of pain and patient problems.
But the workup is fairly straightforward.
Get a urinalysis. Of course, looking for blood.
But do remember that about 10% of cases of
nephrolithiasis have a negative urinalysis for blood.
And that's why we get imaging.
And an ultrasound can be effective.
A lot times, I order a CT urogram
which doesn't require contrast.
But both of these tests can help diagnose
a patient with nephrolithiasis even
regardless of what their urinalysis may show.
Do understand as well that
sometimes the things that we do as
physicians can promote stone formation,
one of which is treatment with antibiotics.
So, those are sulfamethoxazole, amoxicillin, quinolones
are all associated with a higher risk of stone formation.
For patients with diabetes, sulfonylureas can promote stones.
So can potassium-sparing diuretics.
Might be – use those in cases of heart failure.
And then laxatives which is, of course,
a favorite among some of my older adults,
can also be associated with stone formation.
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.
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.
So, two liters or more than two liters every 24 hours,
along with pain management with opiates.
Using calcium channel blockers or alpha antagonists
may help the stone pass a little bit earlier.
So, if patients can tolerate that,
particularly if they're really
uncomfortable, that can be a good idea.
Not a role for corticosteroids among
these patients with small stones.
And they usually do pass on their own.
After it's passed,
make sure that you check basic metabolic panel.
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.
in terms of preventing the next stone for patients,
particularly for calcium oxalate stones,
you shouldn’t be avoiding calcium.
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.
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.
So, you need a specialist on-board.
For prostatitis, this is a picture of the prostate.
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.
It has a lot of room to grow.
And, obviously, when it does,
it’s going to cause obstructive urinary symptoms.
And prostatitis is different from
benign prostatic hypertrophy.
And it often is associated with pain as well.
So, I think the keys to understanding prostatitis,
both for your knowledge and for the exam,
is there are two prevalence peaks.
One during young adulthood
and one during older age.
E. coli is the most common organism.
But you see other organisms that are commonly
implicated in urinary tract infection,
also involved in causing prostatitis.
And this is another one that’s kind
of hard to pin down because
the pain is very difficult for patients to describe.
It's usually more dull, but then it can become sharp.
And the location is really tricky.
So, think about pain in any of those areas – superpubic,
rectal, perineal can all represent prostatitis.
When you do the exam,
this is one of the exams where a
digital rectal examination is necessary.
I don't believe in the digital rectal
examination for asymptomatic patients.
Doesn't really have the sensitivity to detect
prostate cancer or colorectal cancer.
But if you have a patient with potential prostatitis,
they absolutely need to have their
prostate checked with a DRE.
But, however, in doing so, avoid
vigorous prostate massage.
That can actually seed the bloodstream
and therefore promote sepsis,
so a really bad idea.
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.
So, in about a third of cases, the urine
culture is going to be negative.
And also, I'm pretty liberal in testing my
patients for sexually transmitted diseases.
It's classically among patients who are a little bit younger,
but people have sex their whole lives it turns out.
So, therefore, I'm always thinking,
it doesn't hurt to get a culture or a DNA specimen
for gonorrhea and chlamydia as well.
So, just to – again, a demonstration
that the prostate can be large.
It looks painful from here.
Now, how do you treat it?
For outpatients, usually giving a shot of ceftriaxone
and doxycycline for 10 days is enough.
The other option is treat it like a urinary tract infection.
But again, I think the key difference between prostatitis and most
urinary tract infections is the duration of treatment.
So, if you see that there,
we think about – well, we’ll treat a urinary
tract infection in a man for seven days.
For prostatitis, it’s 10 to 14 days because
that infection is kept in the prostate.
It’s harder for the antibiotics to penetrate and,
therefore, need more time with the antibiotics.
For inpatient treatment, don't treat a
lot of inpatients for prostatitis.
But, say, they did develop sepsis related to
their prostatitis, they should definitely come in.
You can still use a quinolone.
It doesn't – and oral and IV are
really equivalent with quinolones.
But for more severe – some severely ill patients,
broad coverage, piperacillin, tazobactam
and probably adding in aminoglycoside.
If they are that sick to come into the hospital and receive piperacillin,
tazobactam, I would add aminoglycoside, if I could.
And then again,
think about a longer treatment duration,
particularly if they’re really sick.
You’re going to treat for up to four weeks.
So, that covers nephrolithiasis and prostatitis,
two important conditions that
usually respond to therapy.
But you also can use your help of your urologic
colleagues for those cases that break through.