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.