Website of Dr. Neil Baum, a urologist in New Orleans, offering evaluation and treatment of urinary incontinence, impotence, male infertility, and diseases affecting kidneys, bladder and sexual organs

Suggestions for Managing Urologic Conditions in Your Patients and Indications for Urologic Referral

Dr. Neil Baum* in conjunction with:
Dr. Alex Weinstein (Santa Barbara, CA)
And
Dr. Joe Kuntz (San Luis Obispo, CA)

The Kidney
The Bladder
The Prostate
Urethral Disorders
The Penis
The Testicles and Scrotum
Miscellaneous Topics

THE KIDNEY

RENAL MASSES

RENAL PAIN

GUIDELINES:

Follow-up with Medicine

  1. <6-7mm ureteral stone - pt should be given oral analgesics, urine strainer and told to push PO fluids; he should then be followed with serial KUBs at 2-4 wk intervals; if stone passes or shows signs of progress down ureter, can continue to follow for 1-2 months as long as patients pain is manageable and not accompanied by UTI. Refer to a urologist if these criteria are not met.
  2. If stone passes, send for stone analysis. These pts do not require referral to a urologist. Advise them to increase water intake for future stone prophylaxis.
  3. Metabolic workup - first-time stone formers do not require any metabolic evaluation. Recurrent stone formers may benefit from metabolic w/u. Pt should be stone-free for 4-6 wks prior to initiating evaluation. The evaluation should include: serum electrolytes, BUN, Creatinine, Ca, P, uric acid and 24-hr urine for Na, creatinine, calcium, uric acid, citrate, oxalate, phosphorous, and magnesium. Follow up of these studies should be either with patient's primary care physician or a nephrologist.
  4. Radiolucent stones are most often uric acid stones which are amenable to dissolution therapy by alkalinizing the urine. Treatment options: Polycitra or Urocit K; need to monitor urine pH and keep pH >7.0 ; follow progress with serial renal ultrasound and\or intravenous pyelograms. (If stones are large i.e. > 1.0- 1.5 cm will usually take too long to dissolve and these patients should be referred to a urologist).

Indications for Referral a Urologist

  1. Large stones in kidney or ureter unlikely to pass spontaneously (>6-7mm).
  2. Smaller stones in ureter that have not passed over a period of 1-2 months, or sooner if causing recurrent bouts of colic requiring repeated trips to ER
  3. Stones in pregnant women
  4. Obstructive stones accompanied by infection (obstructive pyelonephritis) these pts require prompt urologic intervention

Indications for Hospital Admission

  1. Vomiting with inability to tolerate oral fluids
  2. Pain uncontrolled by oral analgesics
  3. Obstructing stone accompanied by infection requires prompt urologic intervention

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THE BLADDER

BACTERIAL CYSTITIS IN FEMALES

NONBACTERIAL CYSTITIS IN FEMALES (Irritable Bladder Syndromes)

These patients have symptoms similar to and often mistaken for bacterial cystitis. The patients complain of frequency, urgency, and\or urge incontinence and nocturia; there is a spectrum of severity ranging from annoying to almost debilitating symptoms. The hallmark for this diagnosis is irritable symptoms and a negative urinanalysis.

Specific Syndromes:

  1. Overactive Bladder
    "frequency/urgency" syndrome; mild end of spectrum can be exacerbated by stress, caffeine, alcohol or nicotine. Urinalysis must be negative
    Rx:
    1. reassurance (benign, albeit chronic disorder)
    2. behavior modification (decrease fluid intake if excessive, decrease caffeine, alcohol or nicotine and start timed voiding if indicated)
    3. Anticholinergics:
      Ditropan XL, 5,10,15mg\day
      Detrol LA, 4mg\day
      Urispas 100-200mg TID-QID
      Levsinex BID-TID
  2. Urethritis
  3. Atrophic Urethritis/Vaginitis
  4. Carcinoma in Situ
  5. Interstitial Cystitis (IC)

BACTERIAL CYSTITIS IN MALES

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THE PROSTATE

BENIGN PROSTATIC HYPERPLASIA (BPH)
General Information

Treatment

Referral to a Urologist

CARCINOMA OF THE PROSTATE
General Information

Screening

Refer to Urology

PROSTATE INFECTIONS

  1. Bacterial Prostatitis

    Signs and Symptoms of Acute Bacterial Prostatitis

    Signs and Symptoms of Chronic Bacterial Prostatitis

    Treatment

  2. Prostatodynia or Chronic Abacterial Prostatitis

    Signs and Symptoms

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URETHRAL DISORDERS

URETHRTTIS

General Information

Symptoms usually consist of marked dysuria or urethral itching and in males more often than females a urethral discharge. Patients may also complain of frequency and urgency

Sexually Transmitted Urethritis

  1. Gonorrheal - usually presents with above symptoms accompanied by thick, yellowish urethral discharge and appearing within 2-10 days after sexual exposure. Stained smear shows intracellular Gram Negative diplococci. Culture for gonorrhea is positive. Treatment:
    Ceftriaxone 250 mg IM x I
    +
    Doxycycline 100 mg BID x 7days
    or
    Zithromax 1gm\day for two days

  2. Nongonococcal - usually chlamydia (50%) or other (10-15%) including ureaplasma, trichomonas, H. Simplex. The discharge in these patients is usually thinner, more scant and usually clear. The recommended treatment for chlamydial or ureaplasma is Doxycycline 100 mg BID x 7days or Zithromax 1gm; for trichomonas treat with Flagyl 2.0 gram single dose or 500 mg BID x 7 days.
    **Always treat exposed sexual partners

Nonsexually Transmitted Urethritis (NSU)

  1. In small percentage of patients urethritis can also be caused by same organisms that cause cystitis; these patients should have positive bacterial cultures of initial voided urine and should have pyuria. Treat with culture-specific antibiotics. Recurrent episodes may reflect underlying pathology e.g. urethral stricture in males or urethral diverticulum in females and these patients need to be referred to a urologist.
  2. Contact sensitivity to soaps, spermicides, detergents clothing dyes or lubricants used during sex may cause noninfectious urethritis. Elimination of chemical irritant should cause symptoms to resolve.
  3. Asymptomatic milky or mucoid urethral discharge during or following a bowel movement represents prostatic fluid expressed into the urethra by increased intrarectal pressure. It is not pathological and no treatment is indicated.

ATROPHIC URETHRITIS

URETHRAL CARUNCLE

URETHRAL STRICTURE

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THE PENIS

CIRCUMCISION

GENITAL WARTS

General Information:

Treatment

PHIMOSIS

PARAPHIMOSIS

Signs and Symptoms

BALANITIS

PEYRONIE'S DISEASE (need information for Verapamil and Website)

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THE TESTICLES AND SCROTUM

TESTICULAR AND SCROTAL MASSES

General information

Most masses that arise from within the scrotum are benign, testicular neoplasm is uncommon but must be ruled out in all cases. Masses that arise adjacent to the testicle are, as a rule, benign and those that arise within the testicle are usually malignant but it can be difficult to differentiate between the two.

Hydrocoele and Spermatocole

The first diagnostic maneuver is to try to transilluminate the mass. A mass that will transilluminate is usually a hydrocoele or a spermatocoele. A hydrocoele in the pediatric patient should be referred to a urologist for repair if the child is over one year of age and referred urgently if it is tender or there is a hernia that becomes incarcerated. An adult hydrocoele is most commonly the result of the failure of the scrotal lymphatics to reabsorb the normal fluid produced by the tunica vaginalis on the testicular surface. They are usually painless but can become quite large. Patients usually are seeking reassurance but will sometimes request referral because the lesion is unsightly or uncomfortable with tight clothing. Some hydrocoeles are associated with epididmytis and are usually painful; some are associated with testicular tumors. In the former case, the hydrocoele may resolve with treatment of the underlying cause. Ultrasound examination is indicated to rule out testicular neoplasm if the testicle cannot be palpated.

Some hydrocoeles do not transilluminate. These are often chronic hydrocoeles that have been inflamed or infected and have an associated thick fibrotic capsule that does not allow the light to pass through. These can be confused with hernias. The examination of the internal/external ring and the presence of bowel sounds in the scrotum can usually make the diagnosis. Omental hernias can be challenging; again ultrasonography is often helpful. A hydrocoele of the cord is simply an inclusion cyst in the processus vaginalis and can be resected if troublesome, i.e., causing pain or is large enough to be cosmetically unacceptable.

A spermatocoele is a cystic collection of fluid and spematocytes resulting from a leak at the level of the rete testis. Again, these are usually asymptomatic and require no treatment. The spermatocoele can be resected if it becomes large enough to trouble the patient of becomes painful.

Varicocoele

A varicocoele is a collection of varicose veins from the pampiniform plexus in the spermatic cord, usually on the left side. The have a doughy irregular feel within the cord, commonly described as "a bag of worms". They are prominent when the patient is upright and when the patient performs the valsalva maneuver; they will often disappear when the patient is supine. Varicocoeles do not transilluminate. If the patient has typical aching with heavy lifting, conservative measures including wearing a bicycle chamois, seat and NSAID's are effective. Varicocoeles can be, but are not invariably, associated with infertility. They can also be associated with testicular atrophy. Varicocoeles associated with abdominal masses, isolated right sided varicocoeles, varicocoeles in infants, varicocoeles associated with testicular atrophy or infertility should be referred to a urologist.

Adenomatoid Tumor

Adenomatoid tumors are small benign pea-like lesions in the tunica albuginia of the testicle. They are painless and are clearly on the surface of the testicle rather than inside the tunica. They require no treatment. Should there be any uncertainty about the diagnosis, an ultrasound is diagnostic.

Sperm Granuloma/Suture Granuloma

A sperm granuloma or suture granuloma is a small painless to slightly tender mass adjacent to the testicle (sperm granuloma) or near the severed end of the vas deferens which occurs after vasectomy. They are the result of the immune response elicited by spermatozoa that leak or by the suture itself. Treatment is symptomatic; heat, NSAID's and scrotal support. If the pain does not resolve, the lesion can be resected.

Lipoma of the Cord

Lipoma of the cord is a painless, rubbery mass in the cord. It will not transilluminate and can be confused with a hernia. It will not reduce; no treatment is required.

Sebaceous Cyst of the Scrotum

Sebaceous cysts occur commonly on the scrotum. They present as small discrete spherical subcutaneous masses filled with sebum. They can be multiple. No treatment is required unless they become infected. Antibiotics and drainage may be required. Some patients request removal for cosmetic reasons in which case the cyst wall must be completely excised.

EPIDIDYMITIS

General Information

  1. Acute infection or inflammation causing swelling and tenderness of the epididymis. In severe/advanced cases, can extend to involve the testis and may be associated with fever, chills and leukocytosis.
  2. Usually secondary to urethritis, prostatitis or cystitis. In young sexually active men suspect underlying sexually transmitted disease; in elderly patients suspect underlying UTI. If UA is positive, obtain Urine C&S.
  3. Onset is usually gradual over several days; may be accompanied by symptoms of lower tract UTI or urethral discharge depending on underlying etiology.
  4. Physical exam: swollen, tender epididymis (lies postero-lateral to testis), and\or erythyema, cord often tender, elevation of testis may help alleviate the pain.
  5. Resolution is usually slow and may take up to 4-6 weeks for complete resolution of swelling/induration.
  6. At times differentiation from testicular torsion may be difficult. Torsion usually has a more abrupt onset and tends to be seen in younger patients. If history and exam equivocal a nuclear perfusion scan of the testicle can be very helpful if available; if not available and question remains, obtain a urologic consult.

Treatment

  1. If urine culture is positive, use sensitivity specific antibiotics for 2-3 weeks.
  2. For empiric treatment, Septra DS bid for 2-3 weeks in the elderly male population and Ceftriazone 250mg IM x I followed by Doxycycline 100 mg bid for 7-10 days in the young sexually active patient.
  3. Supportive measures in the first few days to help alleviate symptoms include analgesics (NSAIDS), scrotal support/elevation, and restriction of strenuous physical activity.
  4. In severe cases with associated fever and symptoms of systemic toxicity, hospitalization with IV antibiotics may be indicated.

Refer to Urology

  1. Referral to Urology is not necessary for isolated cases that resolve with standard therapy.
  2. Refer cases that fail to resolve, recur frequently, or become chronic.

TESTICULAR TORSION

General Information

  1. Spontaneous twisting of the testicle and spermatic cord within the scrotum, strangulating the blood supply to the testicle.
  2. Presents as sudden onset of pain and swelling of the testicle; may be accompanied by nausea, vomiting.
  3. Usually occurs in prepubertal and adolescent boys but may also occur in young adults; unusual in middle-aged and elderly men.
  4. Physical exam: pt in considerable distress secondary to pain; involved testis swollen, often elevated in scrotum and may be rotated on axis so that lying in a transverse rather than vertical plane. The cord above the testis may be thickened; entire testis usually exquisitely tender; unless seen very early there may be diffuse swelling making palpation of anatomical landmarks difficult.
  5. Urinalysis is usually normal. CBC is usually normal but mild leukocytosis may be present.
  6. If trouble differentiating from epididymitis, consider emergency nuclear scan of testis; torsion will show decreased perfusion of testicle and epididymitis will show increased perfusion secondary to inflammation.

Treatment

  1. Torsion of the testis is a urologic emergency: irreversible testicular damage can occur within as little as 4-6 hours. Contact a urologist for emergency consultation.
  2. Obtain stat CBC and UA and keep patient NPO until the urologist evaluates patient; if torsion is suspected patient requires emergency surgical exploration.

TORSION OF THE TESTICULAR AND EPIDIDYMAL APPENDAGES

General Information

  1. Tiny polypoid vestigial appendages are found on the anterior superior surfaces of the testicle and epididymis. These appendages may torse, typically in prepubertal boys.
  2. Presents as sudden onset of sharp testicular pain; unlike torsion of the entire testis though, the pain tends to be localized to the superior pole.
  3. If seen early, careful palpation can often localize point tenderness over the anterior superior surface of the testis or epididymis and if the scrotal skin is drawn tight over this point, you may even see the classic "blue dot" sign (the necrotic appendix).
  4. Clinical signs and symptoms are usually less severe than in testicular torsion but after several hours sufficient testicular swelling may develop making differentiation between the two difficult.
  5. If diagnosis is ambiguous, emergency perfusion scan is desirable if available. Otherwise obtain an emergency urology consult to aid in diagnosis.

Treatment

  1. If diagnosis unequivocal treat symptomatically with analgesics, rest and ice to help reduce the swelling. Symptoms will resolve within a week or so without damage to the testicle.
  2. If diagnosis ambiguous obtain emergency Urology consultation; if any question exists as to the possibility of testicular torsion surgical exploration is indicated.

INFERTILITY

Prior to embarking on an evaluation of infertility, make sure couple has had one year of unprotected intercourse at appropriate time intervals without conception. Both male and female partners should then undergo evaluation of infertility. Prior to any infertility evaluation of the female the male partner should have a formal semen analysis documenting abnormality. The man should abstain from intercourse or should not masturbate for 48 hours prior to the semen analysis. Ideally they should have 2-3 semen analyses as there can be considerable variation from one exam to the next. Patients with abnormal semen analyses should also have serum FSH, LH and testosterone and prolactin levels drawn prior to referral to a urologist.

"NO INCISION" VASECTOMY

  1. Patients need to have an initial consultation several weeks prior to having a vasectomy in order to learn about the procedure, the risks and complications and the instructions following the procedure. At that visit they will be provided educational materials, watch a video on the procedure and sign a consent. If they are married, we request that the wife also sign the consent.
  2. Following the initial consultation patients will be scheduled for the procedure to be performed in the office under a local anesthesia.
  3. Patients need to understand that they are not sterile immediately after the procedure and need to ejaculate 15 times or wait three months and have at least two semen analyses to be sure that no sperm is seen in the ejaculate before they are considered sterile and can have intercourse without the use of any contraceptives.

VASOVASOSTOMY OR VAS REVERSAL

  1. Vasovasostomy is usually not covered by the patient's insurance, therefore, the patients are required to pay for the cost of the procedure.
  2. Patients may obtain cost-estimates from our office manager.
  3. The procedure is done on a one-day stay basis and the patient and partner need to understand that no sperm may be seen in the ejaculate for 3-6 months after the procedure

IDIOPATHIC TESTICULAR PAIN (Idiopathic orchalgia)

  1. Painful testicle(s) in the presence of a completely normal testicular and scrotal exam.
  2. Make sure there are no other signs or symptoms that may indicate nontesticular etiology of the symptoms e.g. hernia, muscle strain, ilioinguinal nerve irritation, ureteral stone or psychogenic problems.
  3. Often, no specific cause can be found for apparently bona fide testicular pain.
  4. In true cases of idiopathic orchalgia, reassure patient that no serious pathology exists (at times it may be indicated to obtain a testicular ultrasound to aid in reassuring patient that no occult testicular mass exists).
  5. Empiric symptomatic treatment may aid as an adjunct to reassurance, e.g. nonsteroidal anti-inflammatory agents, empiric course of doxycycline100mg BID, for 1-2 weeks, avoidance of tight clothes, and switching from boxer shorts to briefs for better scrotal support

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MISCELLANEOUS TOPICS

EVALUATION OF HEMATURIA

Gross Hematuria

  1. Gross hematuria, whether accompanied by pain or not, almost always requires diagnostic investigation. Initial diagnostic studies include IVP and cystoscopy. Sonography, CT scan, bacteriological studies, retrograde pyelography, or other studies may be indicated by individual clinical circumstances. These patients should all be referred to a urologist; an IVP should be obtained prior to referral.
  2. Exceptions to this rule which may not require investigation, or which may require only limited investigation, include:
    1. Hemorrhagic Cystitis: gross hematuria clearly associated with acute UTI and which promptly clears with treatment of the infection, does not require separate diagnostic evaluation. These patients need follow up urinanalyses to be certain that the hematuria has cleared
    2. Exercise Hematuria: isolated episodes of painless gross hematuria soon after strenuous physical exercise, particularly running and jogging, is a recognized and benign syndrome and does not require diagnostic evaluation.
    3. Initial or Terminal Stream Hematuria: blood present only in the first or final portions of the urinary stream originates from the bladder neck, prostate, or urethra. IVP usually is not necessary. Common causes are urethritis, prostatitis, BPH, urethral caruncle, atrophic urethritis, urethral condylomata and hematospermia. Urethral carcinoma is an extremely rare consideration. If history and physical examination do not make the cause clear, or empirical treatment for urethritis or prostatitis does not eliminate the problem, cystoscopy may be indicated.
    4. Anticoagulated Patients with Coagulation Studies Beyond Therapeutic Ranges: anticoagulation meds should be adjusted to bring the patient into therapeutic range; if hematuria persists then evaluate patient in usual fashion for the hematuria; if hematuria resolves, no evaluation indicated.
  3. Gross hematuria associated with proteinuria and casts, with or without pyuria and/or azotemia, suggests glomerulonephritis and should be evaluated as such. These patients should be referred to a nephrologist.
  4. Prior to any diagnostic studies to evaluate gross hematuria, it should be established that the blood does not represent contamination from the vagina, introitus, prepuce or glans penis.

MICROSCOPIC HEMATURIA

General Information

  1. Between 10-15% of adults over the age of 35 will have microhematuria at some time,
  2. Diagnostic evaluation of all patients with microhematuria will reveal some abnormality in slightly less than 50%, and serious urologic disease will be found in only about 2-5%.
  3. There is generally a greater chance of significant disease when larger numbers of RBC's are present. However, serious disease may be present with only a few RBC's/HPF.
  4. Benign Idiopathic Hematuria: the likelihood of serious disease is low in patients who fulfill all of the following low risk criteria, and such patients do not require further diagnostic evaluation:
    1. Urologically asymptomatic.
    2. Normal genitourinary physical exam.
    3. No glomerulonephropathy risk factors:
      1. Proteinuria
      2. Azotemia
      3. Red cell, granular, or hyaline casts
      4. Dysmorphic red cells
      5. Exposure to nephrotoxins
    4. Fewer than 10 RBC's/HPF
    5. No cancer risk factors:
      1. Smoking
      2. Past history of GU cancer
      3. Chronic exposure to aromatic amines
      4. History of schistosomiasis or travel to countries where this parasite is endemic
    6. No past history of major urological disease
    7. Age under 50

Evaluation

  1. Before instituting diagnostic workup, confirm that the patient definitely has microhematuria by both dipstick and microscopic examination of the urine specimen on at least 3 separate specimens. Be sure that the RBC's do not represent contamination from the vagina, introitus, prepuce, or glans penis.
  2. For those patients who do not meet the low risk criteria outlined above, evaluation should proceed with IVP and referral to a urologist for evaluation which includes a cystoscopy.

HEMATOSPERMIA

General Information

  1. Bloody ejaculate, brown ejaculate, or post-ejaculatory gross hematuria or bloody urethral discharge is almost never a sign of any serious disease.
  2. Hematospermia may be found in association with prostatitis or seminal vesiculitis, but in the absence of other signs or symptoms of prostatic infection, hematospermia represents nothing more than "epistaxis" of the prostate at the moment it contracts during emission and ejaculation.
  3. The phenomenon of hematospermia may be a single, isolated event, but it frequently is recurring. It is often very upsetting and alarming to patients and their partners

Treatment

  1. If evidence of prostatitis is present treat accordingly.
  2. In the absence of prostatitis, there is no specific treatment for hematospermia.
  3. Patients should be reassured that nothing serious is wrong. Explain that a tiny and fragile blood vessel within the prostate gland ruptured during ejaculation, like a nose bleed.
  4. Further explain that it is not possible to find or treat the blood vessel causing the problem.
  5. Further explain that the problem can recur, and the patient does not need to be alarmed if it does recur, but that the problem eventually goes away.
  6. Advise the patient that, should he notice hematospermia again, he should abstain from sex for several weeks thereafter, to allow the blood vessel time to "heal" securely.
  7. There is no medical necessity to refer patients with hematospermia for urological consultation unless they refuse to accept the reassurances of other physicians and demand to see a specialist.

SEXUAL DYSFUNCTION

ERECTILE DYSFUNCTION (ED) OR IMPOTENCE

General Information

  1. ED is defined as the inability to achieve and maintain an erection that is adequate for intercourse.
  2. The majority of ED (85%) has underlying physical or organic causes; a minority (10%) of cases are psychogenic in origin. These statistics are especially accurate in men over the age of 50.
  3. Psychogenic ED tends to have a more sudden onset, often triggered by a specific event or set of circumstances. It may be intermittent or situational (e.g., patient gets good erections at some times but not at others, or he gets good nocturnal erections, but not with partners, or partner-specific erections where he has an erection with one partner and not with another). It can be caused by job stress, a dysfunctional relationship, depression, an isolated bad sexual encounter, preoccupation with poor sexual performance, etc. These patients get normal nocturnal and early morning erections. Patients with psychogenic ED can usually be easily identified and can be referred for psychiatric evaluation or sex therapy.
  4. Organic ED is most often secondary to a variety of medical illnesses and/or their treatments. The most common cause of organic ED is vascular causes such as hypertension, dyslipidemia, and atherosclerosis. Diabetes accounts for 33 % of impotent patients and atherosclerotic disease for another 25%; radical pelvic surgery accounts for 10%; other organic causes include neurological diseases such as multiple sclerosis, strokes or spinal cord injuries and hormonal causes.
    Prescription drugs, particularly beta blockers, vasodilators, phenothiazines, thiazide diuretics, antidepressants and antianxiety drugs (SSRIs) can be a source of erectile problems in some patients.
  5. Hormonal impotency, due to low testosterone levels can occur but is not very common. These patients characteristically present with decreased libido and may also demonstrate testicular atrophy on exam. If patients complain of decreased libido obtain a serum testosterone in the morning when the diurinal variation of testosterone is highest and prolactin level; in the presence of normal libido and normal testicular exam these blood tests are usually not necessary.

Treatment

  1. In true hormonal impotency androgen replacement is indicated; however, this is only a small percentage of patients. Administer androgens with caution to elderly males because of the risk of stimulating an occult prostatic carcinoma or BPH. If these men have a normal digital rectal exam and a normal PSA level, then it is safe to offer them testosterone replacement therapy.
  2. If patient is taking antihypertensive medication or other drugs that may cause ED switch to alternative medications if medically feasible. The ACE inhibitors and calcium channel blockers are the least likely to cause ED. Wellbutrin is an SSRI that is less likely to cause ED than other SSRIs.
  3. Patients not falling into either of the above two categories may be tried on the medication Viagra (sildenafil). The initial dose is 50mg Patient need to be instructed to take the medication 45-60 minutes before they engage in sexual intimacy. They also need to be instructed that they will require genital stimulation in order for the erection to occur. The best results are achieved when the man takes the medication on an empty stomach or in the absence of a high fat meal. Also, alcohol seems to impede the absorption of the medication. The men also need to know that they may have to try the medication for 6-8 times before they are successful.

    Levitra (vardenafil) is also a phosphodiasterase-5 inhibitor that can be taken with food. The starting dosage is 10mg and can be increased to 20mg. The drug should not be used in conjunction with alpha-blockers such as Cardura, Hytrin, or Flomax. 3.

    The side effects, which are uncommon, include headaches, sweaty palms, dizziness, nervousness and nausea. Men may also complain of discoloration around bright lights but this complaint is usually transient and will subside in just a few hours.

    None of the oral therapies, i.e., Viagra or Levitra, should be prescribed in men who use or could use nitrates such as sublingual nitroglycerin or nitroglycerin patches.

  4. Prior to embarking on more invasive treatment options it is important to first ascertain the patient's motivation to do so. The patient and ideally his partner as well, need be motivated and willing to actively participate in the treatment of this problem. If they are pursuing the treatment options just out of curiosity or because they feel as if they should meet some baseline standard of performance they are unlikely to be good candidates for additional therapy.
  5. External Vacuum Therapy: a simple, safe and non-surgical method of producing a quality erection. The device consists of a plastic cylinder, a pump, and a special constriction ring. The patient inserts his penis into the cylinder after first pre-loading the constriction ring onto the cylinder; the pump is then used to create negative pressure that results in engorgement of the penis. When fully erect, the ring is transferred to the base of the penis to maintain the erection during intercourse. The devise is effective in 80-90% of patients. There is a learning curve involved and the patient needs to be patient and to have realistic expectations.
  6. Penile Injection Therapy: certain vasoactive drugs injected directly into the corpora cavenosa of the penis have been found to produce good erections in up to 65% of impotent patients. The most common drugs used are Papaverine, Phentolamine and Prostaglandin El. These medications are most effective in patients with neurogenic ED but can work in patients with mild to moderate degrees of vasculogenic ED. It is essential to have a highly motivated and responsible patient; there are potential complications of these treatments if used improperly e.g. infection, hematoma formation, pharmacologically induced priapism. Some patients on this therapy have also been found to develop fibrous plaques in the penis; the long-term implications of these are unknown.
  7. Penile Prostheses: entails surgical placement. There are two main types of implants, the malleable form which is always erect but bends for concealment, and the inflatable form which in addition to the two penile cylinders has a reservoir and pump device allowing inflation and deflation of the device. Placement of a penile prosthesis requires a one-day stay surgical procedure. The success rate is >90%.

PREMATURE EJACULATION

General Information

  1. Premature ejaculation is a psychologically conditioned response pattern which usually improves well with behavior modification methods of psychotherapy.
  2. There is usually no known organic cause of premature ejaculation.
  3. Occasionally a patient will see the doctor with the chief complain plain of ED, when actually the problem is premature ejaculation, following which he loses his erection. Question the patient carefully about what is happening.
  4. No specific testing is indicated or available for premature ejaculation
  5. Treatment consisting of SSRIs include:
    Zoloft, 25-50mg 2-4 hours before intercourse
    Anafranil, (sertraline) 25-50mg 4 hours before intercourse

URETHRAL CATHETERIZATION

Troubleshooting Tips for Catheterization

  1. The most commonly used catheters for routine catheterization are Foley latex catheters, 16F or 18F. These sizes are small enough to minimize patient discomfort and large enough to provide free urinary drainage. Special types of catheters are indicated for specific cases and will be described below.
  2. Catheters should be liberally lubricated with a water-soluble lubricant prior to introduction. The contents of the small lubricant packets usually included in prepackaged catheterization kits or available separately on the hospital wards are often inadequate. Liberal lubrication both increases the ease of catheter passage and decreases patient discomfort during the procedure. As an alternative, 5-15cc of either plain lubricant, K-Y jelly, or Xylocaine jelly may be instilled directly into the urethra for additional lubrication and/or local anesthesia in a very anxious patient or in whom the catheter would not readily pass the first time.
  3. Never inflate Foley balloon until urine is draining from the catheter. If you think you are in the bladder and no urine is draining, irrigate catheter with a catheter-tipped syringe. If you are in the bladder, the catheter will irrigate freely. You may then inflate the balloon (we usually use 10cc in the 5cc balloons) and withdraw the catheter from the urethra until you feel the balloon's resistance against the bladder neck. Make sure you tape the catheter to the patient's thigh to avoid accidental removal of the Foley.
  4. If you are unable to pass a 16F or 18F catheter beyond the prostate or bladder neck, you will be more likely to succeed by trying a larger catheter than a smaller one. Smaller catheters are softer and more likely to buckle and kink when resistance is encountered.
  5. In some males with BPH the prostatic urethra may make a sharp turn anteriorly before reaching the bladder neck, and conventional catheters may have difficulty "making the turn." In such situations, using a Coude catheter, which has an angled tip, may be successful. Always pass a Coude catheter in such a fashion that the tip will be angled anteriorly when it reaches the prostatic portion of the urethra.
  6. While steady advancement pressure of a well lubricated (especially if lidocaine jelly has been instilled into the urethra) catheter will often overcome resistance of BPH or sphincter spasm, strong force should never be used.
  7. When resistance to catheter passage is encountered despite taking above measures, try and ascertain at what level the obstruction is, e.g. distal urethra, bulbar urethra, prostate or bladder neck. You may be dealing with a stricture. Stop, and call a urologist for further advice and assistance.
  8. If a patient is in large volume (> 500cc) acute urinary retention of many hours duration, a catheter usually should be left indwelling for several days to a week, to allow the bladder to decompress and regain its tone. Following straight in-and-out catheterization such patients are likely to develop recurrent retention. These patients should therefore be discharged home with the Foley in place, given instructions on care, leg bags for daytime use and regular bedside Foley bag (larger volume accommodation) for nighttime use. A consult should be sent to a urologist for follow-up. These patients will be seen within 5-7 days for a voiding trial.
  9. Clot Retention: This can be a difficult situation to resolve. However, with the appropriate catheters and patience most of these cases can be handled in the Emergency Department. The key to irrigating clots out of the bladder is to use a catheter of sufficient diameter, and at times, even a special catheter that has a greater number and larger size of holes at the end of the catheter to facilitate evacuation of clots. Taking the extra time and effort will frequently save the patient an emergency cystoscopy which could require a trip to the operating room. Initially a 22F or 24F Foley can be passed and vigorous manual irrigation with a catheter-tip irrigating syringe employed. It is advantageous to not inflate the Foley balloon initially for two reasons: first, the pressure of the inflated balloon may narrow the caliber of the catheter lumen and secondly, in irrigating clots out of the bladder you need to be able to move the catheter in and out; most clots will settle onto the floor of the bladder and you will not be able to irrigate these out with the catheter inserted up to its hub, but rather only when it is pulled back several centimeters so that the holes at the end of the catheter are just inside the bladder neck. Continue irrigating manually until no further clots come out and until the irrigation fluid flows easily in and out of the catheter and the color of the effluent irrigant changes from dark burgundy/red to light pink/clear.

    If you are unable to do this through the 22F or 24F Foley, obtain a "6-eye" catheter of similar size; the 6-eye catheters are designed specifically for clot irrigation. They have 6 holes rather than the stand 2 holes at the tip of the catheter and the holes are also of larger diameter to allow easier passage of clots into and through the catheter. These catheters do not have a balloon on the end and therefore cannot be left indwelling; if it is indicated to leave a catheter in the patient after clot evacuation, a second Foley, usually a 22-24F, needs to be placed.

    Patients who are in clot retention with old-appearing clots (brownish/burgundy colored) can usually be sent home without a catheter. Old clots usually represent prior bleeding rather than current, ongoing bleeding. If any small clots are remaining, they can actually be more readily passed out by voiding through the urethra than through even the largest of Foley catherters. However, if the color of the clots and urine is bright red, this implies fresh, ongoing bleeding and these patients are likely to develop recurrent clot retention. These patients are often best managed by insertion of a 3-way irrigation catheter (once all the clots are evacuated) and then started on continuous bladder irrigation (CBI). A urologist should be contacted if any questions regarding need for admission for CBI. Otherwise, if patients meet criteria for clot evacuation in ER and discharged to their home, consultation should be obtained with a urologist for outpatient follow-up.

INCONTINENCE

Definition: condition in which the involuntary loss of urine is a social or hygienic problem and is objectively demonstrated.

ETIOLOGIES

  1. BLADDER DYSFUNCTION
    1. Motor Instability - bladder demonstrates involuntary or uninhibited detrusor contractions at relatively low volumes. The various causes are:
      1. Idiopathic
      2. Neurogenic - upper motor neuron lesion, e.g. spinal cord injury, myelodysplasia, CVA, multiple sclerosis
      3. Obstructive - 15% of men with BPH demonstrate associated detrusor instability
      4. Irritative - infectious versus noninfectious, e.g. foreign body, CIS, interstitial cystitis
    2. Sensory-Urgency Syndrome - intense sensation to void at low volumes; also known as urethral syndrome, irritable bladder syndrome.
    3. Low-Compliance Bladder - poor bladder compliance resulting from radiation therapy, chronic infection, or chronic inflammation from other causes.
    4. Overflow Incontinence - failure of bladder to empty urine secondary to neurogenic disease (e.g., lower motor neuron lesion, DM), pharmacologic side effects (e.g., anticholinergics, sedatives) or bladder outlet obstruction (e.g. BPH, stricture); pressure of retained urine in bladder eventually results in dribbling of urine from overdistended bladder.

  2. URETHRAL INCONTINENCE
    1. Intrinsic Disease
      1. Mucosal/Submucosal Impairment - due to loss of estrogens in postmenopausal women, surgical scarring or radiation injury.
      2. Sphincter Injury - occurring after a prostatectomy, usually a radical prostatectomy and rarely after a TURP, or other surgery/trauma.
      3. Innervation Damage - secondary to pelvic nerve injury from surgery, DM, peripheral autonomic neuropathies, pharmacologic agents.
    2. Anatomic Displacement - results in stress urinary incontinence (SUI) or the involuntary loss of urine which occurs due to a sudden increase in intra- abdominal pressure in the absence of a detrusor contraction. SUI is due to a weakening of pelvic floor support that results in downward and posterior displacement of the bladder neck and urethra causing the unequal transmission of pressure that results in urinary leakage. SUI tends to occur in women after multiple pregnancies, a difficult delivery.

  3. FUNCTIONAL INCONTINENCE
    1. Impaired mobility
    2. Impaired mental function
    3. Environmental factors
    4. Medications or disease

TREATMENT

  1. BLADDER DYSFUNCTION
    1. Motor Instability
      1. If neurogenic, pharmacologic treatment:
        1. Anticholinergics/Musculotropics
          - Detrol LA, 4mg\day
          - Ditropan XL, 5, 10, or 15mg\day
          - Urispas 100-200mg TID-QID
          -Oxytrol 3.9mg patch applied once every 3-4 days or twice weekly
        2. Tricyclic antidepressants
          - Imipramine 25-l00mg/day
      2. If obstructive, relieve obstruction, e.g. TURP
      3. If irritative, treat underlying problem e.g., treat CIS or UTI
      4. If idiopathic, pharmacologic treatment and\or behavior modification (e.g., timed voiding)
    2. Sensory-Urgency Syndrome - anticholinergics and\or behavior modification
    3. Low Compliance - anticholinergics and surgical treatment if necessary (bladder augmentation)
    4. Overflow
      1. If neurogenic, Clean Intermittent Catheterization (CIC), or less desirable, indwelling Foley
      2. If obstructive, relieve obstruction, e.g. TURP

INDICATIONS FOR UROLOGIC REFERRAL

  1. Pharmacologic failure
  2. Hematuria, especially if uninfected
  3. Recurrent UTIs, especially with relapse of the same organism
  4. Pelvic pain, dysuria, frequency, urgency and negative UA and urine cultures
  5. Significant anatomic defect, i.e., cystourethrococele
  6. Severe stress incontinence

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