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Urgent Urologic Disease

by Charles Vega, MD
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    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.


    About the Lecture

    The lecture Urgent Urologic Disease by Charles Vega, MD is from the course Acute Care. It contains the following chapters:

    • Urgent Urologic Disease
    • Prostatitis

    Included Quiz Questions

    1. Calcium oxalate
    2. Calcium phosphate
    3. Uric acid
    4. Struvite
    5. Cysteine
    1. ...a history of gout
    2. ...a history of pseudogout
    3. ...a history of thiazide diuretic use
    4. ...a history of recurrent urinary tract infections
    5. ...a history of calcium-channel blocker use
    1. ...a history of recurrent urinary tract infections
    2. ...a history of gout
    3. ...a history of chondrocalcosis
    4. ...a history of dietary calcium supplementation
    5. ...a history of alpha-antagonist use
    1. Thiazide diuretics
    2. Sulfonylureas
    3. Amoxicillin
    4. Spironolactone
    5. Ciprofloxacin
    1. Low dose thiazide diuretic
    2. Low dose potassium sparing diuretic
    3. Avoid excess calcium in diet or supplements
    4. Prophylactic regimen of amoxicillin
    5. Titrated dose of laxatives
    1. E. coli
    2. Pseudomonas aeruginosa
    3. Neisseria gonorrheae
    4. Klebsiella
    5. Enterococcus

    Author of lecture Urgent Urologic Disease

     Charles Vega, MD

    Charles Vega, MD


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