R. Matthew Smith M.D. Mercy Urology

Disclosures

None

Goals

Update growth of Mercy Urology Clinic Quick Review of Hematuria and PSA Present common urologic complaints seen

by the primary care physician BPH OAB / Urge Incontinence

Mercy Urology

Started seeing patients 9/6/2016 Current complement: Physician: One full time (Me), weekend locum coverage Jerry Murphy 5/2017 Nathalie Francois starting 8/2017

Mid Levels NP Identified, starting in 1-2 weeks

What are we seeing

Cancer Prostate Bladder Kidney Testicular

Voiding Dysfunction: BPH overactive bladder/urgency/urge incontinence incontinence

Infection: Chronic UTI Reproduction: Vasectomy Peds: Circumcision, bed wetting, reflux

Our number so far . . .

September through January New Patients: 516 (410)

Sep: 61 (51) Oct: 125 (77) Nov: 138 (98) Dec: 98 (90) Jan: 94 (94)

Procedures: 158 Sep: 2 (2) Oct: 26 (23) Nov: 35 (31) Dec: 39 (39) Jan: 46(46)

OR

Surgery Total: 158

Sep: 18 Oct: 32 Nov: 53 Dec: 55 Jan: 55

What are we doing Cysto / Stent: 23 Ureteroscopy / laser: 31 Bladder tumor: 15 Davinci : 2 (prostatectomy / nephrectomy)

From Idle to Full throttle

We are busy Ramp up of clinic faster than expected Booking into April . . .

Struggles Access Adding NP to take acute patients and returns

How can you help If you have someone that needs to be seen – let me know

Inbox, text, call If you have someone that has a non-urgent problem . . .

Consider holding referral for a few months

New Ventures

Advanced Prostate Cancer clinic In Office evaluation for Sacral Nerve

Stimulation Urodynamics program

Future Growth

Men’s health clinic ED Testosterone

Metabolic Stone clinic Run by NP?

Incontinence Center Pelvic floor rehab PTNS Biofeedback

Hematuria Review

Seeing increased ordering of upper tract imaging prior to urologic evaluation

We are performing more same day cystoscopy (at time of hematuria NP visit)

Some things to remember: Any (Most?) Gross Hematuria gets workup For microhematuria: MUST have a micro. MUST have 3

or more RBC per HPF Dip doesn’t count. Importance of getting micro at time of dip

UA order – dip with reflex to micro

Prostate Cancer The importance of the DRE/PSA

Case Studies . . . . RG: 65M, otherwise healthy, micro hematuria. PSA 0.9

Distinct small nodule on PSA . . . Gleason 9 cancer EB: 81M, prostatectomy 2001. PSA negligible x 10 years

Referral for GH. DRE: HARD right rectal mass. Workup: PSA 15, right hydro, large R pelvic mass

4+4=8 recurrent prostate cancer DH: 68M, Initial screening PSA 1300, DRE: Bilateral nodules

Extensive metastatic disease JM: 81M for voiding trial. DRE: extensive nodules

PSA: 70, Extensive local disease.

Voiding Physiology

The bladder has 2 functions Filling (Storage) Emptying

Voiding Physiology

Filling phase Absence of involuntary contractions Accommodation

Compliance – viscoelastic properties of the bladder Neurogenic bladder: poor compliance – high pressures –

dangerous! Sympathetic stimulation relaxes bladder Parasympathetic inhibition relaxes bladder

Closed bladder outlet Sympathetic stimulation

Voiding physiology

Normal Emptying Absence of obstruction (BPH, stricture, etc) Open bladder outlet

SNS inhibition – decreases involuntary sphincter tone Onuf’s nucleus (somatic) inhibition – decreases voluntary

tone

Coordinated detrusor contraction PNS STIMULATION SNS INHIBITION

Voiding Pnemonic

Sympathetic nervous system promotes Storage

Parasympathetic nervous system promotes Peeing

BPH

BPH Occurs in the transition zone As men age, Increase in prostate stroma tissue

Growth into the lumen – obstruction of flow Growth mediated by 5-alpha-reductase

Increase in # of alpha-1 receptors Increase in smooth muscle tone

BPH

Lower Urinary tract symptoms

Obstructive Symptoms Decreased force of stream, hesitancy, intermittancy, post void

dribbling Irritative symptoms

Urgency, Frequency, Nocturia Bladder outlet obstruction from BPH

Increased smooth muscle tone Prostate growth into lumen of prostate Degree of obstruction does not correlate with severity of

symptoms Definitive test for BOO is urodynamics

Trabeculations

Cellules

Divertiucla

Evaluation and Tx of BPH

History and Physical **** Includes DRE

Assess severity and bother Formal or Informal (IPSS)

Frequency / Volume chart Post Void Residual (EUA not AUA guideline) PSA (Diagnostic, not screening) UA (Diagnostic, not screening)

Evaluation and Tx of BPH

History and Physical **** Includes DRE

Assess severity and bother Formal or Informal (IPSS)

Frequency / Volume chart Post Void Residual (EUA not AUA guideline)

PSA (Diagnostic, not screening) UA (Diagnostic, not screening)

BPH Danger signs Early Urologic Referral

Recurrent / Persistent urinary retention Recurrent UTI Recurrent / Persistent gross hematuria Recurrent / large bladder stones Hydronephrosis or renal insufficiency

Evaluation and Tx of BPH

If no danger signs, assess bother No bother – Surveillance Bother Non invasive Tx or meds Obtain voiding diary Polyuria – polyuria eval

Persistent / worsening disease Advanced eval with urology

Assessing for BOO

PVR Measurement Scanner or catheter

Uroflow Max, average flow; flow time; flow curve

Cystoscopy Trabeculations / cellules / Diverticula

Urodynamics – low flow with high detrusor pressure

Non Invasive Treatment

Alter Non BPH factors Avoid substances that promote retention

Alpha agonists (pseudophed) Anticholinergic or B3 agonist

. . . . But we often use them for LUTS management Caffeine, spicy food, alcohol – may decrease OAB symptoms

Nocturia Decreased fluid intake Avoid night time diuretics

Surveillance Repeat evaluation every year

Phytotherapy

Not recommended by AUA Efficacy data are lacking ? Some men may benefit

Commonly used substances Saw Palmetto (Serenoa repens) African Plum Stinging nettle Pumpkin seed African Star grass Rye grass pollen

Alpha blockers

Inhibit alpha-1 adrenergic receptors, relaxing smooth muscles in prostate and bladder neck

Prostate has alpha-1-A receptor Alpha-1-B in blood vessels Alpha-1-D in nasal passages – congestion

Non-selective alpha blockers Terazosin (Hytrin), doxazosin (cardura),

alfuzosin(uroxatal) Selective Alpha blockers

Tamsulosin (flomax), sildosin (Rapaflo)

Effects Flow effects

Usually occurs within 8 hours for alpha-1-A selective 2-4 weeks for non selective

Symptom effects Begin in 1-3 days, may take several months to reach

maximum effect Side Effects

Dizziness, fatigue, nasal congestion, orthostatic hypotension (uncommon), syncope (rare) Retrograde ejaculation (28% sildosin, 18% tamsulosin)

Intraoperative Floppy Iris Syndrome

Any prior use of alpha blockers put a patient at risk of intraoperative floppy iris syndrome during cataract surgery Ophthalmology needs to know prior to procedure

5-alpha-reductase inhibitors

Finasteride (proscar), and Dutasteride(Avodart) Blocks conversion of Testosterone to Di-Hydro-

Testosterone Reduces prostate volume by 20-25% Increases flow by 10% Improves symptom score by 25% Decreases episodes of acute retention by 50% Decreases PSA by 50% (9-12 months) Decreases chronic hematuria from prostate

5-alpha-reductase inhibitors

Finasteride (proscar), and Dutasteride(Avodart) Blocks conversion of Testosterone to Di-Hydro-

Testosterone Reduces prostate volume by 20-25% Increases flow by 10% Improves symptom score by 25% Decreases episodes of acute retention by 50% Decreases PSA by 50% (9-12 months) Decreases chronic hematuria from prostate

5AR Side Effects

Impotence (<5%) Decreased libido (<4%) Decreased volume of ejaculate (<3%) Gynecomastia (<1%) Does finasteride increase risk of high grade prostate

cancer? Probably not – Increase in incidence likely due to

increased yield.

Tadalifil

Used for Erectile dysfunction and BPH Improves max flow rate Comparable to tamsulosin for decreasing symptoms

from BPH Other PDE-5 not approved (short half life; prn dosing)

Tadalafil is long half life, can be given daily

Combination Tx MTOPS / CombAT trials

Alpha blocker and finasteride/dutasteride Combination therapy is better than either agent alone

Progression of BPH Monotherapy ~ 60% Dual thearpy ~ 35%

Prevention of acute retention Monotherapy (5ARI) – 68% Dual therapy – 81%

Reduction in need for surgery Monotherapy (5ARI) – 64% Dual therapy – 67%

BPH and Overactive Bladder

BOO from BPH may cause over-activity Secondary effect on bladder

OAB may occur in absence of BOO See next section

No OAB meds are approved for BPH I use them in men with Primarily irritative symptoms

and low PVR

OAB / Urge Incontinence

OAB – clinical diagnosis “urinary urgency, usually accompanied by frequency and

nocturia, with or without urge incontinence, in the absence of a urinary tract infection or other obvious pathology”

Risk factors Age Chronic obstruction (BPH) Pregnancy Vaginal delivery Postmenopausal status CNS disorders (stroke, SCI, etc)

Most common cause: idiopathic

Stratifying OAB Complicated

Severe symptoms Young age Gross Hematuria Recurrent UTI Significant Pelvic Organ Prolapse Fecal Incontinence Constipation Hx of pelvic cancer, pelvic/vaginal surgery, radiation Neurologic disease Impaired mobility Poorly controlled DM

Uncomplicated None of the above

Workup/Tx for uncomplicated OAB

Workup History / Physical, Urinalysis

Assess bother Behavioral Therapy

Timed voiding (q2hrs while awake) Fluid Management Avoid bladder irritants (caffeine, spicy foods, etc) Avoid constipation Weight loss Smoking Cessation Pelvic floor therapy (Kegals) – Hold 6-8 secs, relax. X10, TID

Oral Meds

Oral Meds - anticholinergics

Inhibit muscarinic receptors, which reduce detrusor over-acitivty

All anticholinergics have similar efficacy Improved efficacy if combined with Pelvic floor muscle

therapy Initial Improvement in 1 week, may take up to 3 months Contraindications:

Urinary retention Gastric retention – concurrent K theraphy Intestinal obstruction Uncontrolled narrow angle glaucoma Myasthenia Gravis

Oral Meds - Anticholinergics

Side Effects Dry mouth Constipation Blurry vision Headache Dizziness Drowsiness Rare: Tachycardia, Urinary retention, Cognitive

impairment, impaired perspiration

Anticholinergic Meds

Oxybutynin (Ditropan) Short acting / long acting. Highest rate of dry mouth/ constipation / cognitive

impairment Tolteridine (Detrol) Darifenacin (Enablex) Solifenacin (Vesicare) Fesoteridine (Toviaz) Trospium (Sanctura) – least effect on CNS (quaternary

amine)

How do I pick an anti-cholinergic?

Side Effects Try not to use Immediate release oxybutynin Sanctura for elderly

Cost Whatever their insurance will pay for ‘Don’t let them touch it’

B3 agonist - Mirabegron

Actively relaxes detrusor muscle Bladder contains all 3 Beta receptors

B3 most abundant B1 – increase HR, BP (kidney – renin; vascular –

contraction) Mirabegron has low affinity for B1/B2 Start to see effects at 4 weeks, may take 8-12 for full effect SE: Increased BP (10% - don’t give in uncontrolled HTN,

monitor), Headache (3-4%), Nasopharyngitis (3-4%), Tachycardia (rare), Retention (rare)

Refractory/Complicated OAB Further workup PVR Voiding Diary Cytology Renal U/S Cystoscopy Urodynamics

Surgical Tx of OAB

Botox Onabutulinumtoxin-A (OBTA) Inhibits release of acetylcholine from vesicles in the

presynaptic side of the neuromuscular junction. Efficacy

60-75% of pts see improvement of 50% or more 30-40% see complete resolution

Duration: 3-12 months SE:

UTI Urinary retention (must be willing to self cath) Systemic spread is rare

Percutaneous Tibial Nerve Stimulation

Percutaneous needle electrode stimulates Tibial Nerve (S3 root)

Leads to modification of voiding reflex Treatment course

30 min weekly x 12 weeks Customized maintenance schedule

Efficacy: Significant improvement in 60% of patients. Contraindications: Pasemaker/Defibrillator,

coagulopathy, pregnancy

Sacral Nerve Stimulation (Interstim)

Modifies voiding reflex by stimulating S3 afferent nerve 2 stage process

In office or OR test If test shows improvement, implantation of permanent

generator Indications: Failure of conservative Tx for OAB, Urge

Urinary Incontinence, urgency, frequency, Non-obstructive urinary retention.

Efficacy: 50% dry 60-90% improved

Interstim

Contraindications Need for MRI Previous damage to sacral nerves

Review Hematuria

Get a microscopic urine

Prostate Cancer DRE, strongly consider PSA

BPH Alpha blockers/5ARI are mainstays of treatment Look for danger signs

OAB Uncomplicated/mildly complicated

treat with anti-cholinergics / mirabegron

Complicated or refractory: Urology referral

Future Topics - ???

Erectile Dysfunction Bladder Pain Syndrome / Interstitial Cystitis Premature Ejaculation . . . You tell me . . . .

Thank You