A guide to the management of urologic dilemmas for the primary care physician (PCP)

Patients with urologic conditions may present to a primary care physician (PCP) in the emergency department or in the PCP's office. Some conditions are true emergencies that require immediate surgical intervention. Others may require medical treatment or possibly simply reassuring the patient that there is no serious medical problem. Sometimes the diagnosis can be easily made, whereas other times the PCP needs to be able to rule out serious causes for a presenting problem and execute a guideline-recommended patient work up, to make a final diagnosis. Sometimes recommended diagnostic tests may not be readily available. When a PCP believes that a patient may have a serious urologic condition and is unsure of the appropriate patient management strategy, then he or she must quickly refer the patient to a urologist. This article describes common urology-related issues-hematuria, prostate-specific antigen (PSA) test interpretation, phimosis and paraphimosis, acute scrotal pain and masses in the child and adult, urinary tract infection, renal colic, and castration-treatment-induced bone loss. It provides insights into decision-making processes for patient management of some urologic conditions, and information about managing sequelae and side effects of long term treatment. It includes practical diagnostic suggestions and patient management strategies based on the authors' years of urologic clinical practice experience.

[Integrative approaches to the diagnosis and treatment in urology]

Modern medical science is characterized by the rapid development of diagnostic equipment, the introduction of more sophisticated and science-based technology in the diagnosis and treatment of diseases. Features of the urologist's work in the modern world and the diversity of manifestations of urologic diseases require close cooperation between physicians of different specialties. Interdisciplinary cooperation is necessary and urgent not only for professionals but also for patients. The authors summarize and present the problems that connect urologists with colleagues in medicine, biology, and other areas of our life.

Therapeutic applications of lasers in urology: an update

There has been renewed interest in the use of lasers for minimally invasive treatment of urologic diseases in recent years. The introduction of more compact, higher power, less expensive and more user-friendly solid-state lasers, such as the holmium:yttrium-aluminum-garnet (YAG), frequency-doubled neodymium:YAG and diode lasers has made the technology more attractive for clinical use. The availability of small, flexible, biocompatible, inexpensive and disposable silica optical fiber delivery systems for use in flexible endoscopes has also promoted the development of new laser procedures. The holmium:YAG laser is currently the workhorse laser in urology since it can be used for multiple soft- and hard-tissue applications, including laser lithotripsy, benign prostate hyperplasia, bladder tumors and strictures. More recently, higher power potassium-titanyl-phosphate lasers have been introduced and show promise for the treatment of benign prostatic hyperplasia. On the horizon, newer and more effective photosensitizing drugs are being tested for potential use in photodynamic therapy of bladder and prostate cancer. Additionally, new experimental lasers such as the erbium:YAG, Thulium and Thulium fiber lasers, may provide more precise incision of soft tissues, more efficient laser lithotripsy and more rapid prostate ablation. This review provides an update on the most important new clinical and experimental therapeutic applications of lasers in urology over the past 5 years.

[Lower urinary tract dysfunction: neurogenic bladder after radical pelvic surgery for cancer]

The incidence of permanent lower urinary tract dysfunction(LUTD)after radical pelvic surgery has been estimated to range from 15% to 20%. Although this surgery is often curative, it is unfortunate that patients suffer from permanent LUTD. Urodynamic study can help in adequate management of the lower urinary tract, in order to prevent long-term upper and lower urinary tract complications. In addition to residual urine measurements, uroflowmetry is required as a screening or follow-up tool for the evaluation of LUTD. Reasonable knowledge of clean intermittent catheterization is also indispensable.

[Analysis of grant of special nephrological help to childrensi in Chernivtsi region]

Nephrological morbidity is important indicator of the state of the health of children's population. The aim of this study is analysis of the activity of nephrological service care for children's population of the Chernivtsi region. The material for this study is reporting documentation about the condition of the nephrological service care for children's population of the Chernivtsi region in 2008-2012 and the data of The Center of medical statistics of Ministry of Health of Ukraine. The incidence of prevalence of diseases of the urinary system between teenagers of Chernivtsi region during the 2008-2012 period had a wave-like nature and have lower rates comparing general Ukraine rates, with the exception of 2011, when the incidence of child population in the region amounted to 32.60 in 1000 to 29.65 against children 1000 children in Ukraine. The age structure of patients is determined by many factors, including the demographic situation in the region, "continuity" and these primary healthcare units. Value of microbial and inflammatory diseases to nephropathy--2.9:1 (2009), but over the last three years there is a tendency to change its value--3.5-4:1 (2012). Is marked resistance to antibiotic therapy--3/4 of surveyed high school age children and teenagers found mycoplasma pathogens (M. hominis, M. genitalium) and ureaplasma (U. urealyticum) origin, especially against the background of comorbidity of "modern child". Analyzes the main indicators of child nephrology service in Chernivtsi region. The research, carried out by authors, will allow to hold the reasoned medical and rehabilitation events in all stages of rendering of specialized medical care for teenagers with nephrological pathology and to develop the programs, directed on improvement of indicators of health and prevention of disability in children.

[Benefit of a specialized multidisciplinary clinic in neuro-urology and functional urology]

Functional disorders encounter for a large amount of the medical activity, including in urology. The decreased quality of life due to lower urinary tract symptoms requires a prompt management, with primary assessment undergone in community. Referral to a specialist is required when simple management has failed, and whenever any of these coexists: hematuria, recurrent urinary infection, and neurological condition. The specialized clinic in neurourology and functional urology aim at further investigating the underlying disorder responsible for the urinary symptoms and preventing urinary tract complications. A multidisciplinary team is the key to accurately assess patients with regards to their bother and handicap, therefore offering the most appropriate conservative, medical or surgical management.

The diagnosis and management of lower urinary tract symptoms in multiple sclerosis patients

Sixty-five percent of multiple sclerosis patients have moderate to severe urinary symptoms and up to 14% initially present with urinary symptomatology. Urinary retention, neurogenic detrusor overactivity, and detrusor sphincter dyssynergia, all increase the risk for urinary tract infections in patients with multiple sclerosis, and these infections may exacerbate their immune response, leading to symptom progression. Fewer than half of the patients with urinary symptoms have seen a specialist and only half have been treated for their neurogenic detrusor overactivity. Several treatments including pelvic floor muscle therapy, pelvic floor electrical stimulation, anticholinergics, desmopressin, sacral nerve neuromodulation, posterior tibial nerve stimulation, cannabinoids, and intravesical therapy with vanniloids, as well as botulinum toxin, have all been shown to be effective in treating urinary symptoms in those with multiple sclerosis. Clean intermittent catheterization is invaluable in patients with persistent urinary retention to avoid infection and upper tract dysfunction. Indwelling transurethral catheterization should be avoided because of the high risk of infection. Identification and successful treatment of these urinary conditions will improve the health and quality of life for these men and women.

[New puncture techniques in urology using 3D-assisted imaging]

The selective use of various puncture techniques for diagnostic or therapeutic purposes is a component of the daily routine of urologists. The aim of these interventions is always a safe and rapid puncture at the appropriate target point. Nowadays, imaging systems are increasingly being used in urology with the aim to achieve a more precise and safer planning and execution of punctures through an increased accuracy by the use of 3D representation. An approach to the solution to achieve this aim is the fusion of 3D reconstruction by magnetic resonance imaging (MRI) or computed tomography< (CT) with real-time imaging procedures, such as sonography or fluoroscopy.

Adolescent urology update

The transition from childhood to adulthood can be tricky. For patients who present later in life with conditions usually addressed earlier in childhood, such as enuresis, there can be pressing social and psychological concerns. For other conditions that previously had not seen many children progress into adulthood, we now must try to fine-tune our care to consider the degree of independence of patients, and to find an appropriate adult physician to continue their care.

Critical urologic skills and procedures in the emergency department

The evaluation and management of genitourinary emergencies is a fundamental component of the training and practice of emergency physicians. Urologic procedures are common in the emergency room. Emergency physicians play a vital role in the initial evaluation and treatment because delays in management can lead to permanent damage. This article discusses the most common urologic procedures in which emergency physicians must be proficient for rapid intervention to preserve function and avoid complications. An overview of each procedure is discussed as well as indications, contraindications, equipment, technique, and potential complications.

THE PROFILE AND UROLOGICAL SERVICE NEEDS OF OUTPATIENTS ATTENDING A TERTIARY CENTRE IN WESTERN KENYA

BACKGROUND

Urological service needs cut across varied ages and related conditions. The outpatient attendance is a reflection of the common conditions constituting the urological burden of a given population (1). The urological burden in turn has implications on access to care and treatment (2) since it will determine the skills needed, mode of treatment, amount of time and other resources required to meet these needs. There is, therefore, a need to have a local data base on the profile of our urological patients and their needs with regard to modes of treatment. This study strives to and meets this important objective.

OBJECTIVE

To establish the epidemiology of outpatient urology patients and their service needs as seen in a tertiary centre in the Western region of Kenya.

DESIGN

Hospital based observational, descriptive, prospective, cross sectional study.

SETTING

The Urology Outpatient clinic of Moi Teaching and Referral Hospital (MTRH), a 750 bed tertiary centre in the Western region of Kenya catering for approximately half of the Kenyan population.

SUBJECTS

Ninety-four first time attendees to the urology clinic seen in the year 2011.

MAIN OUTCOME MEASURES

The primary outcome measures were the demographic data and diagnosis while the secondary outcome measure was the urological service needs of the patients in terms of treatment as to whether surgical or medical at presentation.

RESULTS

Ninety-four patients attended the urology clinic for the first time in the year of study. The male to female ratio was 14.7: 1. Age ranged from one year to 97 years with a mean ± standard deviation of 48.0 ± 25.3 years. Half were below and half were above 50 years of age. Males had longer durations of symptoms compared to females but the difference was not statistically significant (p = 0.131). The top three urological problems were urethral strictures, prostate diseases and Urinary Tract Infections. There was an overall 70.2% need for surgical interventions with twenty-six point one percent of the prostate disorders being managed medically while all urethral strictures were planned for surgery. The odds ratio for surgery after one year compared to within first year of symptoms was two.

CONCLUSION

The urological patients attending this tertiary outpatient clinic are predominantly males and are widely spread out in terms of age and diagnosis. The clinical burden of urethral strictures has overtaken that of prostate diseases in this tertiary centre.

Implementing an action protocol on prostatic disease in primary care and impact on referrals to urology

OBJECTIVES

To determine the impact of implementing a joint action protocol on prostatic disease on the referrals to Urology from Primary Care in a health care area.

METHODS

We drafted a protocol for managing patients consulting for clinical signs and symptoms associated to benign prostatic hyperplasia (BPH) and to test PSA in asymptomatic males. At the same time, three e-mail addresses were opened for consultations generated from Primary Care, and joint sessions were carried out in the primary health care centers. We measured the impact of the protocol by assessing the adequacy of prostatic disease referrals to Urology, as well as by determining the course of the total number of referrals in three peripheral specialized health care centers (PSHCC).

RESULTS

From January 2011, a better compliance to the referrals to Urology protocol for prostatic disease has been produced, going from 47% (assessment prior to implementing the protocol) to 64%. These results are especially good when we consider referrals associated to PSA, which went from a compliance of 33% to 84%. Regarding the course of the referrals to Urology, the referral rate (referrals per 1000 inhabitants) has decreased by 15% (from 13,8 to 11,7).

CONCLUSIONS

The collaboration between Urology and Primary health care, by means of implementing joint protocols, and also by establishing new communication channels (e-mail, joint sessions), achieves a better adequacy of patients referred for prostatic disease, as well as a reduction in the total number of referrals.

[Relationship of systemic factors in the pathogenesis of chronic pelvic pain syndrome in men]

Survey of 250 men with category III chronic pelvic pain syndrome/ chronic prostatitis (CPPS/CP-III) showed that the urological disease often proceeds against the background of obesity (29.6%), androgen deficiency (38.4%), increased tone of sympathetic nervous system (62.9%) and the activation of the plasma lipid peroxidation system (oxidative stress) (100%), with significant correlations between these factors. Working hypothesis was formulated; according this hypothesis, the components of metabolic syndrome in men and associated systemic reactions of sympathetic hyperactivity, oxidative stress, and androgen deficiency play an important role in the pathogenesis of CPPS/CP-III. This allows to consider CPPS/CP-III as an interdisciplinary complex issue of men's health and to review the existing traditional approaches to its diagnosis, treatment and prevention.

[Current state, challenges and prospects for the development of the Russian urological service]

The present study was dedicated to the analysis of the incidence, prevalence and mortality from diseases of the urogenital system. The data on the effectiveness of the hospital bed usage, the patient profile at hospital, the treatment timing and outcomes, surgical activities in urological hospitals, the state of staff assistance in urological service, the efficacy of usage of working time of urologist and human resource of Russian urological service were analyzed. Data analysis revealed a number of issues of administrative and legal nature, which cause modest efficiency of activity of urological service. The ways for solutions of these problems are presented.

[Urological problems in pregnancy, birth, and puerperium--a systematic review]

Urological problems in pregnancy represent a diagnostic and therapeutic challenge. Urinary tract symptoms in pregnant women comprise urinary tract infections, urolithiasis, hydronephrosis, urinary retention, urinary frequency and urinary incontinence. The primary purpose of this paper was to link our current understanding of the urinary tract anatomy and physiology to urinary tract symptoms in pregnancy and puerperium and the secondary purpose was to provide a review on diagnosis and management of these.

Urological manifestations of sarcoidosis

PURPOSE

We describe the urological manifestations of sarcoidosis and how the disease may affect the management of multiple urological conditions.

MATERIALS AND METHODS

We performed a PubMed® search using the query sarcoidosis and multiple urological terms.

RESULTS

Sarcoidosis is a disease that has variable manifestations. There is often genitourinary involvement that is clinically silent. However, sarcoidosis may cause symptoms, such as nephrolithiasis, which are sometimes the first manifestation of the disease. Renal function may be affected, and appropriate recognition and treatment may avert progressive functional decline. The presence of sarcoidosis may also confound the diagnosis and staging of various urological malignancies, particularly renal and testicular carcinoma.

CONCLUSIONS

Urologists should be aware of the urological manifestations of sarcoidosis to avoid misdiagnoses and the over staging of urological cancers, and to identify when it is an underlying cause of nephrolithiasis or obstructive uropathy.

A survey evaluating the current role of the nurse practitioner in urology

The role of the nurse practitioner (NP) continues to expand into the care of specialty populations. This article presents results of a survey that allowed NPs who self-identified as working specifically with people diagnosed with urologic conditions to describe their clinical role. The purpose of identifying NP-specific clinical tasks was to provide evidence to be used in revising the urology specialty certification examination for NPs.

Implications of pacemakers and implantable cardioverter defibrillators in urological practice

PURPOSE

Pacemakers and implantable cardioverter defibrillators are widely used and often encountered in urology practices worldwide. Safety and performance during electrosurgery, extracorporeal shock wave lithotripsy, magnetic resonance imaging, positron emission tomography and radiotherapy are not clearly defined. We reviewed the literature on their use and implications in urological practice.

MATERIALS AND METHODS

We performed a PubMed® search and all relevant articles were studied to understand the basic functioning of these devices along with the technological advances designed to reduce electromagnetic interference.

RESULTS

A modern permanent pacemaker is comprised of a generator and leads connecting to the atrial or ventricular myocardium with sensing and pacing functions. Implantable cardioverter defibrillators respond to episodes of ventricular tachycardia and fibrillation by discharging a defibrillating current. From a device perspective, several protective mechanisms have been developed in the permanent pacemaker/implantable cardioverter defibrillator to reduce the effects of electromagnetic interference. These involve generator material changes, lead modification, and better sensing and pacing algorithms. Magnetic resonance imaging compatible pacemakers have now been developed and are approved for use in Europe. From a urologist's perspective 5 procedures require the close monitoring of permanent pacemaker/implantable cardioverter defibrillator function. 1) For electrosurgery modifications in the device and in the methods of use have been recommended. 2) For extracorporeal shock wave lithotripsy the European Association of Urology provides some guidance with regard to patients with these devices. 3) During positron emission tomography the pulse generator and the lead area should be covered with lead to protect the device. 4) Magnetic resonance imaging is contraindicated but currently trials are under way for a new pacing system for safe use in the magnetic resonance imaging environment. 5) Patients can undergo radiotherapy with standard precautions but those with an abdominal permanent pacemaker/implantable cardioverter defibrillator require careful planning. Finally, implanted devices should have a full evaluation before and after the procedure.

CONCLUSIONS

Clear guidelines are essential given the rapid advances in technology to enhance patient safety. Magnetic resonance imaging should be avoided in patients without a magnetic resonance imaging compatible device. However, patients can undergo extracorporeal shock wave lithotripsy, radiotherapy and positron emission tomography as long as the device is not in the path.