Wartinger MOA 2016 Geriatric Urology Final with editing … Document… · · 2018-03-19Bypass the liver with other delivery methods. ... • Ejaculation less forceful ... during

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Michigan Osteopathic AssociationDavid D. Wartinger, D.O., J.D.

Michigan State UniversityCollege of Osteopathic Medicine

May 13, 2016 1400 -1830

Integrated Treatment of the Adult Geriatric Male Patient

BPHProstate CancerLow TestosteroneErectile DysfunctionIncontinenceHematuria

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The Urological “Magic Bullet”

5 – alpha Reductase InhibitorProscar/Avodart

Alpha Adrenergic BlockerMinipress / Hytrin / Cardura / Flowmax / Uroxatrol/ Rapiflo

Testosterone ReplacementAndroderm / Androgel / Testim/ Axiron/ Fortesta/ Natesto / Striant / injection or implant / not Oral

Erectile DysfunctionViagra/ Levitra / Cialis

1st choice for symptomatic BPH, low T and ED

Avodart 0.5 mg PO q daily

Uroxatrol 10 mg PO q daily

AndroGel 2 pumps q AM applied to skin

Cialis 5 mg PO q bedtime

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Transitional Zone develops BPH

Peripheral Zone develops CaP

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Obstructive Voiding Symptoms

Decreased force of streamHesitancyStrainingIncomplete bladder emptyingNocturia

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Irritative Voiding Symptoms

FrequencyUrgencyOccasionally dysuria

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Voiding Dysfunction Factors

Changes in bladder, prostate and /or urethra Bladder instability Decreased bladder compliance Urethral stricture; bladder neck contracture

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BPH Natural History

Incidence of AUR or Significance PVR 2% per year

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Figure 2. The validated AUA Symptom Score tool for voiding symptoms

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Medical Therapy for BPH

Shrink or stop growth of prostate Open urethral channel within prostate

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Inhibit Production of DHT

finasteride (Proscar) 1992 dutasteride (Avodart) 2001

Prevent or reduce acinar gland growth

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Relax Smooth Muscle of Prostate and Bladder Neck

Alpha Blockers◦Antihypertensives terazosin (Hytrin)doxazosin (Cardura)

◦Prostate Specific tamsulosin (Flomax)alfuzosin (Uroxatrol)

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Minimally Invasive Procedures for BPH

Transurethral microwave procedures (TUMT)Transurethral needle ablation (TUNA)Water-induced thermotherapyHigh intensity focused ultrasound (HIFU)

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Conventional Surgical Therapy

Transurethral Resection of the Prostate◦“Gold Standard” treatment◦Resectoscope◦60 – 90 minute operation◦Wire loop◦General or spinal anesthesia

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Laser Surgery Variations for BPH

Photo selective Vaporization of the Prostate (PVP)Interstitial Laser Coagulation (ILC)

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Prostate Cancer: Screening and Management

Prostate Cancer (CaP)

Treatment Stratagem

• Early detection while tumor confined to prostate or surrounding tissues and can be cured by either removal or treatments aimed at the primary

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PSA and Overdiagnosis

Identification of patients with CaP that don’t benefit from diagnosis or treatment of their disease

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United States Preventative Services Task Force (USPSTF)

“Fair evidence that [PSA Screening] is ineffective or that harms outweigh the benefits.”

• PSA screening and DRE in asymptomatic patients

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AUA DISAGREES with USPSTF

• PSA used since 1986, total CaP deaths decreased ≈ 30%

• Decreased “dire consequences “ of advanced CaP

• American Cancer Society (ACS) and the American Society of Clinical Oncologists (ASCO) agree with AUA

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Localized Prostate Cancer Treatment

• Radiation• Surgery• Cryosurgery• High intensity focused ultrasound• Expectant management (watchful waiting)

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Hormone Therapy for CaP

• Most commonly used after metastasis

• Only palliative, not curative

• Hormone refractory or androgen independent

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Summary of CaP Treatment

• No free lunch

• Surgery with 30 year life expectancy, localized CaP

• Radiation or expectant management for patients, over 70 years of age and localized CaP

• Metastatic CaP, palliative with hormone manipulation

Testosterone Replacement

1. Only men with symptoms of low testosterone

2. Blood levels confirm low testosterone as cause of symptoms

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Symptoms of Low Testosterone

Low sex drive (libido) Erectile dysfunction Fatigue and poor energy level Decreased muscle mass Hair loss Difficulty concentrating Depression Irritability Low sense of well-being

Forms of TestosteroneSkin patch (transdermal): Androderm – worn on arm or upper body, applied once a

dayGels: AndroGel and Testim – absorbed through skin, applied once

a day, comes in packets AndroGel, Axiron and Fortesta – comes in pump Natesto – gel applied inside the noseMouth Patch: Striant – tablet sticks to upper gums, applied twice a dayInjections and implants: Injection directly into the muscles Implanted pellets into the soft tissueOral ? Negative effects on liver Bypass the liver with other delivery methods

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Risks of Testosterone Therapy Rash, itching or irritation at application site Evidence for increased risk of:

Heart attack Stroke Acne Fluid Retention Breast Enlargement Decreased Testes Size Increased Aggression Mood Swings Decreased Sperm Count Infertility PSA Increase Cholesterol/Lipids

Benefits and Risks of long-term testosterone therapy are

UNKNOWN.

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Conditions that may worsen with testosterone therapy Benign Prostatic Hypertrophy (BPH):◦ Prostate grows naturally under the stimulation of testosterone

Prostate Cancer (CaP):◦ Can stimulate prostate cancer to grow◦ Screen for CaP before starting testosterone◦ CaP or elevated PSA should probably not receive testosterone

treatment Sleep Apnea Blood Clots:

Risk of deep vein thrombosis and pulmonary embolism Congestive Heart Failure

Testosterone Replacement vs. Performance – Enhancing Steroids

Testosterone replacement only achieves physiologic levels of hormone

Doping uses much higher doses of testosterone and often combined (“stacked”) with other substances

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Definition

• The inability to achieve and maintain an erection sufficient for satisfactory sexual intercourse

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Erectile Dysfunction

• Estimated to affect 20-30 million men in the US

• One or more factors• Psychological• Neurologic• Hormonal • Arterial• Venous

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Erectile Dysfunction

• “Silent Marker” for later development of cardiovascular disease

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Figure 1. Anatomy of the Penis. The penile erection occurs as a result of 3 processes: a) smooth muscle relaxation among arteries and trabecular tissue increases blood flow, which b) lengthens and enlarges penis through sinusoidal filling, and c) expanded sinusoids compress the subtunical venous plexus, reducing venous outflow.

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Block Phosphodiesterase Enzyme Activity

• Sildenafil

• Vardenafil

• Tadalafil

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Hormonal ED• Androgen deficiency

• Decrease in nocturnal erections decreases libido

• Erections with visual sexual stimulation preserved

• Androgen may not be essential for erection

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Sexual Function over time• Progressively declines in “healthy” aging men

• Latent period between sexual stimulation and erections increases

• Erections are less turgid

• Ejaculation less forceful

• Ejaculatory volume decreases

• Refractory period between erections lengthens

• Decrease in serum testosterone

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Recommended Laboratory Tests

• Urinalysis

• Complete Blood Count

• Fasting blood glucose

• Creatinine

• Cholesterol

• Triglycerides

• Testosterone

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If Testosterone low

• Serum free (or bioavailable) testosterone

• Prolactin

• Lutenizing hormone

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Erectile dysfunction is not just a sexual health issue,

it may be a serious harbinger of life-threatening cardiovascular conditions

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ED is as important a CV disease risk factor as Smoking, or

Family history of Heart Disease

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Erectile Dysfunction – Treatment

Drug Therapy

• Administration: oral, injected directly into penis, inserted into distal urethra

• March 1998 sildenafil, first pill

• Vardenafil and tadalafil

• Phosphodiesterse (PDE) inhibitors

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Intracavernosal Injections

• Inject drugs into penis to engorge with blood

• Papaverine hydrochloride, phentolamine, and alprostadil (a prostaglandin E2)

• Widen blood vessels, induce and maintain erections

• Side effects: persistent erection (priapism) and scarring

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Erectile Dysfunction – TreatmentIntraurethral Injections

• Insert pellet of alprostadil into urethra, prefilled applicator

• MUSE, inch into urethra

• Onset 8 to 10 minutes, may last 30 to 60 minutes

• Side effect: penile pain, warmth or burning sensation in urethra, redness of penis, minor urethra bleeding or spotting

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Vacuum Erection Devices

• Creates partial mechanical vacuum

• Draws blood into penis, engorging and expanding it

• 3 components: plastic cylinder, pump and elastic band

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Penile Surgery

• Procedures to improve erections1. Implant a device, make rigid2. Reconstruct arteries, improve

flow3. Occlude veins, prevent leak

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Urinary Incontinence• Often treatable

• Identify patients who might benefit from treatment

• Treatment depends on etiology

• Identify the etiology

Urge Incontinence

• Sudden sensation to void

• Unable to suppress sensation fully

• Severe case, may not be aware sensation until actually leaking

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Overactive Bladder (OAB)

Newer term

Frequency and Urgency

With or without

Urge Incontinence

Overflow Incontinence• Occurs at extreme bladder volumes, or

• Bladder volume reaches the limit of viscoelastic properties

• Elevation in detrusor pressure

• Incomplete bladder emptying• Obstruction• Poor bladder contractility

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Overflow Incontinence

Symptoms

• Constant dribbling

• Extreme frequency

Evaluation of the Incontinent Patient• History

• Physical examination

• Laboratory tests

• Possibly urodynamic testing

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Evaluation of the Incontinent Patient

Urinalysis

• Hematuria

• Pyuria

• Glucosuria

• Proteinura

• Cytology, if hematuria or irritative voiding symptoms


Urine Culture and Sensitivity if

• Pyuria

• Bacteriuria

• Treat infection prior to further W/U

• > 3 RBC/HPF, further investigation

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Post Void Residual (PVR)

• Measure with ultrasound or catheter

• Normal <50ml / >200 ml abnormal

• Increased PVR,• Bladder outlet obstruction• Poor bladder contractility• Differentiate with urodynamic testing

Treatment of Urinary Incontinence

Urge Incontinence

• Bladder contracts with or without warning

• Timed voiding

• Remind patients to void every 1-2 hours during the day

• Void before urge to void

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Urge IncontinenceAnticholinergic – Antimuscarinics

• Mainstay of medical therapy

• Side Effects• Urinary retention• Dry mouth• Constipation• Nausea• Blurred vision• Tachycardia• Drowsiness• Confusion

Urinary IncontinenceUrge Incontinence

Poor Bladder Compliance

• Primary Goal: treat high bladder pressure

• Complete bladder emptying• ICC and anticholinergics

• May add to anticholinergic –antimuscarinics and alpha-agonists

• Bladder augmentation when medical management fails

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Urinary IncontinenceTreatment of Urinary Incontinence


• Treated by emptying the bladder

• Relieve Obstruction

• Males

• Urethral stricture• Prostatic obstruction


Urethral Stricture Disease

• Urethral dilation

• Internal urethrotomy

• Urethroplasty

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Prostatic Obstruction

• “Gold Standard” TURP

• Transurethral Resection of the Prostate



• Poor detrusor contractility

• ICC (intermittent clean catheterization)

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Indwelling Catheters

• Not optimum long term treatment

• Eventually infected urine

• Predisposes to bladder calculi

• Possible ultimate squamous cell carcinoma


Males with Stress Incontinence

• Artificial urinary sphincter• Cuff compresses bulbar urethra “Gold

Standard”

• Male slings• Compress under urethra

• Elevate the urethra to more retro pubic position

• Lesser degrees of incontinence, pad weight test

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Urinary IncontinenceSummary – Key Diagnostic Points

Urge Incontinence

• Symptoms

• Urgency

• Frequency

• Nocturia

• Unable to reach the toilet with urge


Stress Incontinence

• Symptoms

• Leakage with physical activity

• Signs

• Bladder neck mobility

• Positive stress test

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Mixed Incontinence

• Symptoms• Urgency• Frequency• Nocturia• Unable to reach the toilet with urge• Leakage with physical activity

• Signs• Bladder neck mobility• Positive stress test



• Symptoms• Frequency• Nocturia• Urgency• Leakage with physical activity

• Signs• High post void residual

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Urinary IncontinenceSummary – Key Treatment

Urge Incontinence

• Avoidance of bladder irritants

• Timed voiding

• Pelvic muscle exercises

• Weight loss


Urge Incontinence• Anticholinergics – Antimuscarinics -

Nonselective for M3 Receptor• Propantheline (Pro-Banthine)

• 7.5 to 30 mg orally, three to five times daily

• Tolterodine (Detrol LA)• 4 mg orally daily

• Trospium (Sanctura)• 20 mg orally two times daily

• Solifenacin (Vesicare)• 5 – 10 mg orally, daily

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Urge Incontinence

• Anticholinergics – Antimuscarinics –Selective for M3 Receptor

• Darifenacin (Enablex)• 7.5 to 15 mg orally, daily


Urge Incontinence

• Anticholinergic – Antimuscarinics/Smooth Muscle Relaxant

• Oxybutynin• Regular (Ditropan)

• 2.5 to 5.0 mg orally, one to three times daily

• Extended Release (Ditropan XL)• 5 – 30 mg orally, daily

• Transdermal (Oxytrol)• 4.9 mg patch twice per week

• Hyoscyamine (Lesin)• 0.125 to 0.375 mg orally, two to four

times daily

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Urge Incontinence

• Anticholinergic/Alpha-Agonist• For urge or mixed

• Imipramine (Tofranil)• Not FDA approved for this indication• 10 to 25 mg, once to three times daily


Stress Incontinence

• Behavioral Changes• Weight loss• Quitting smoking• Pelvic muscle exercises

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Stress Incontinence

• Alpha Agonists• Pseudoephedrine (Sudafed)

• Not FDA approved for this indication

• 30 to 60 mg, up to four times per day


Stress Incontinence

• Anitcholinergics / Alpha – Agonist• Imipramine (Tofranil)

• Not FDA approved for this indication

• 10 to 25 mg, once to three times daily

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0.000ml

0.008ml

0.017ml

0.034ml

0.068ml

0.125ml

0.250ml

0.500ml

1.000ml

2.000ml

4.000ml

8.000ml

1.000SG – U

Row A

1.010SG – U

Row B

1.020SG – U

Row C

HEMATURIA REFERENCE CHARTMICHIGAN STATE UNIVERSITY

Column = Added ML Blood Per Cup Rows = Specific Gravity of Urine SG – U Specimen Cup 50 ML

1 2 3 4 5 6 7 8 9 10 11 12

OBJECTIVE:

This study was approved by the Michigan State University IRB: IRB#: 11-808SI

Very small amounts of blood can be visually detected in the urine and may be the only warning sign of a life threatening problem. A systematic documentation of the visual appearance of gross hematuria specimens was not previously performed. The clinical advantage of possessing a library of photographs documenting exact volumes of blood in known urine specimen volumes was not appreciated. To simulate hematuria, known quantities of anti-coagulated blood were added to 50 ml urine specimens of various specific gravities/concentrations and then photographed on white graph paper. The gross hematuria specimen photographs were arranged sequentially to create a Hematuria Reference Chart. An unknown hematuria specimen can now be visually matched to the Hematuria Reference Chart to determine blood loss per ml of voided urine. The Hematuria Reference Chart is available on-line to health care professionals and patients for documentation, education and diagnosis.

Cancer Trauma Inflammation Infection Foreign Bodies Vascular Glomerular Disease Hematologic Activity Menstruation Loin Pain –Hematuria Syndrome

Hematuria is not normal and its cause must be determined. Most episodes of gross hematuria are not due to life threatening conditions or diseases; but, some episodes are the only warning sign of a life threatening problem. Very small amounts of blood can be visually detected in urine and the amount of blood does not reliably predict the seriousness of the underlying cause of the hematuria. The presence of visible blood in the urine can cause fear and anxiety in patients and healthcare providers alike. Accurately estimating the volume of blood mixed in the urine can help direct treatment and eliminate unwarranted concerns of serious blood loss. Without a reference standard, estimating blood loss from hematuria is imprecise and without scientific basis.

A photographic library of simulated gross hematuria specimens was created and arraigned to produce a hematuria reference chart. Voided urine was collected from a solitary volunteer during various hydration states to obtain urine of different specific gravities / concentration. Increasing amounts of whole anti-coagulated blood were added to volumes of collected urine to create 50 ml simulated gross hematuria specimens. The simulated gross hematuria specimens were photographed (in clear urine specimen cups) on white graph paper background with blue lines. All of the simulated gross hematuria specimen photographs and the Hematuria Reference Chart were uploaded to YouTube and Google Images.

ABSTRACT

INTRODUCTION

CAUSES OF HEMATURIA

METHODS AND MATERIALS

PROCEDURE FOR USING HRC

Example:

Step 1:Verify a total of 50 ml of gross hematuria sample in a clear standard 120 ml urine specimen cup viewed on a background of white graph paper.

Step 2:Select the most appropriate row based on urine specific gravity and match the unknown specimen to the column of added blood on the HRC.

Step 3:Calculate blood loss from hematuria (Voided volume/50 X added blood volume from HRC/cup) = total whole blood loss in ml/void.

If patient voids 500 ml:

500ml/50=10; 10 x 0.034ml= 0.34 total whole blood loss ml/void

DISCUSSION

The online availability of the Michigan State University College of Osteopathic Medicine Hematuria Reference Chart enables patients and health care providers to quantify and document hematuria. Even when patients don’t have online access to the Hematuria Reference Chart, they can photograph their hematuria specimen using a smartphone and send the pictures to their caregiver for comment. Urinary blood loss can now be tracked over the duration of the disease. The Hematuria Reference Chart is both an educational and diagnostic tool with documentation capabilities.

VISUAL ESTIMATION OF BLOOD IN GROSS HEMATURIA

David D. Wartinger, D.O., J.D. Osteopathic Surgical Specialties College of Osteopathic Medicine Michigan State University Shannon Grochulski-Fries

IRB #02-970/APP #i008313

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Wartinger MOA 2016 Geriatric Urology Final with editing … Document… · · 2018-03-19Bypass the liver with other delivery methods. ... • Ejaculation less forceful ... during