Essential Urology - part 1 pps

Klein, MD, SERIES EDITOR Essential Urology: A Guide to Clinical Practice, edited by Jeannette M.. Essential Urology: A Guide to Clinical Practice is intended to provide support to primar

A Guide to Clinical Practice

Edited by

Essential Urology

ESSENTIAL UROLOGY

C URRENT C LINICAL U ROLOGY

Eric A Klein, MD, SERIES EDITOR

Essential Urology: A Guide to Clinical Practice, edited by Jeannette M Potts, 2004 Management of Prostate Cancer, Second Edition, edited by Eric A Klein, 2004 Management of Benign Prostatic Hypertrophy, edited by Kevin T McVary, 2004 Laparoscopic Urologic Oncology, edited by Jeffrey A Cadeddu, 2004

Essential Urologic Laparoscopy: The Complete Clinical Guide, edited by

Stephen Y Nakada, 2003

Pediatric Urology, edited by John P Gearhart, 2003

Urologic Prostheses: The Complete Practical Guide to Devices, Their Implantation,

and Patient Follow-Up, edited by Culley C Carson, III, 2002

Male Sexual Function: A Guide to Clinical Management, edited by

John J Mulcahy, 2001

Prostate Cancer Screening, edited by Ian M Thompson, Martin I Resnick,

and Eric A Klein, 2001

Bladder Cancer: Current Diagnosis and Treatment, edited by Michael J Droller,

2001

Office Urology: The Clinician’s Guide, edited by Elroy D Kursh

and James C Ulchaker, 2001

Voiding Dysfunction: Diagnosis and Treatment, edited by Rodney A Appell,

2000

Management of Prostate Cancer, edited by Eric A Klein, 2000

© 2004 Humana Press Inc.

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No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher.

All articles, comments, opinions, conclusions, or recommendations are those of the author(s), and do not necessarily reflect the views of the publisher.

Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information published and to describe generally accepted practices The contributors herein have carefully checked to ensure that the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication Notwithstanding, as new research, changes in government regulations, and knowledge from clinical experi- ence relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the product information provided by the manufacturer of each drug for any change in dosages or for additional warnings and contraindications This is of utmost importance when the recommended drug herein is a new or infrequently used drug It is the responsibility

of the treating physician to determine dosages and treatment strategies for individual patients Further it is the bility of the health care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical practice The publisher, editors, and authors are not responsible for errors or omissions or for any consequences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication.

responsi-Production Editor: Robin B Weisberg

Cover illustration layout by Jeannette M Potts Cover illustration by Michelle Wolf Cover design by Patricia F Cleary This publication is printed on acid-free paper

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of the Transactional Reporting Service is: [1-58829-109-X/04 $25.00].

Printed in the United States of America 10 9 8 7 6 5 4 3 2 1

E-ISBN 1-59259-737-8

Library of Congress Cataloging-in-Publication Data

Essential urology : a guide to clinical practice / edited by Jeanette M.

Potts.

p ; cm (Current clinical urology)

Includes bibliographical references and index.

ISBN 1-58829-109-X (alk paper)

1 Genitourinary organs Diseases.

[DNLM: 1 Urologic Diseases 2 Urogenital Diseases WJ 140 E78

2004] I Potts, Jeanette M II Series.

RC871.E883 2004

616.6 dc22

2003016746

To my children, Bradley and Ellen, and to my mentors, Jonathan Ross, MD and Elroy Kursh, MD

Dedication

vii

As a medical urologist with a background in family medicine, I have enjoyed theoverlapping aspects of urology and primary care Urological diseases are often brought

to the attention of primary care providers who must then diagnose and manage these

disorders Essential Urology: A Guide to Clinical Practice is intended to provide support

to primary care physicians through its review of common genitourinary problems It ismeant to enhance the recognition of urological disease as well as outline current manage-ment strategies

Disorders of the urinary tract may be encountered during pregnancy, either as a maternal

diagnosis or as a fetal anomaly detected in utero Children as well as adults require screening

and monitoring of genitourinary disorders, some of which are gender-specific Urinary tractinfections may be manifestations of risk factors, anatomical or functional abnormalities,specific to age and/or gender These issues are presented in this text Hematuria, frequentlyencountered in the primary care setting as an incidental finding, is discussed in a comprehen-sive chapter, followed by related chapters detailing urological imaging studies and the evalu-ation and management of nephrolithiasis, respectively Urinary function is addressed in thechapters reviewing female incontinence, interstitial cystitis, and bladder outlet obstructionsecondary to benign prostatic hyperplasia Screening for urological cancers, particularlyprostate and bladder cancers, is reviewed We have included a chapter summarizing comple-mentary therapies in urology and a chapter that introduces alternative approaches tofrequently diagnosed abacterial prostatitis/pelvic pain syndrome Finally, we address thequality-of-life impact and medical significance of erectile dysfunction and its treatment

Essential Urology: A Guide to Clinical Practice addresses various life stages and

respective urological conditions and should be a valuable resource to family ners, internists, pediatricians, obstetricians, physician’s assistants, and nurse clinicians

practitio-Jeannette M Potts, MD

Preface viiList of Contributors xiValue-Added eBook/PDA xii

1 Management of Urologic Problems During Pregnancy:

A Rationale and Strategy 1

4 Screening and Early Detection for Genitourinary Cancer 47

Ian M Thompson and Joseph Basler

5 Basic Imaging in Urology 61

Martin B Richman and Martin I Resnick

6 Hematuria 91

Mark J Noble

7 Evaluation and Medical Management of Kidney Stones 117

John C Lieske and Joseph W Segura

8 Management of Female Urinary Incontinence 153

Raymond R Rackley and Joseph B Abdelmalak

9 Interstitial Cystitis 169

Kenneth M Peters

10 Urinary Tract Infections in Adults 183

Joseph B Abdelmalak, Sandip P Vasavada, and Raymond R Rackley

11 Evaluation and Treatment of Benign Prostatic Hyperplasia 191

Elroy D Kursh

12 Prostatitis/Chronic Pelvic Pain Syndrome 203

Jeannette M Potts

13 Erectile Dysfunction 213

Drogo K Montague and Milton M Lakin

14 Complementary Medications in Urology 225

Elliot Fagelman, Bridgit Mennite, and Franklin C Lowe

Index 235

Contents

ix

2 Loughlin

PHYSIOLOGICAL ALTERATIONS DURING PREGNANCY

Changes occur in the cardiovascular, respiratory, hematological, gastrointestinal, andrenal systems during pregnancy Total blood volume increases by 25 to 40% by the end

of pregnancy (1) This is predominantly a consequence of a 50% rise in plasma volume that begins in the first trimester and reaches a peak between 24 and 28 wk gestation (2).

A smaller increase of approx 15% occurs in red blood cell volume, and the consequence

of this hemodilution is a fall in hematocrit This hemodilution results in an increase of

the free fraction of protein-bound drugs that can alter their effects and toxicity (3–5).

The cardiovascular system during pregnancy becomes hyperdynamic to meet creased metabolic demands Cardiac output is increased by 30 to 50% by the third

in-trimester (1) with a redistribution of cardiac output that effects increased blood flow to

the placenta, uterus, skin, kidneys, and mammary glands Simultaneously, systemicvascular resistance is reduced as a result of vascular relaxation caused by increased

progesterone and prostacyclin (6,7).

The gravid uterus may cause compression of the great vessels during the second half

of pregnancy This can result in reduced aortic blood flow below the level of obstruction

as well as decreased cardiac output when venous return is impaired (5).

The respiratory system is also dramatically affected during pregnancy One of themost crucial changes is a 20% reduction in functional residual capacity by the fifth month

of pregnancy (8) This phenomenon, coupled with a 15% increase in oxygen

consump-tion, causes the pregnant mother to be at increased risk of becoming hypoxemic duringperiods of hypoventilation Pregnant women have a more rapid rate of decline in PaO2

than nonpregnant women (9) Aside from the proportionally greater increase in plasma

volume as compared with red cell volume, which results in the so-called physiologicalanemia of pregnancy, other critical hematologic changes occur Most importantly, theblood of the pregnant patient becomes hypercoagulable This is to the result of severalactivities, the first being an increase in factors VII, VIII, X, and fibrinogen during

pregnancy (10) In addition, the fibrinolytic activity of the plasma is depressed (11,12),

as well as both a reduction of the velocity of venous blood flow in the lower extremities

and a rise in venous pressure (12,13) All of these factors contribute to a significantly

increased risk of venous thromboembolism in the pregnant woman This risk appears to

be greatest in the third trimester or immediately postpartum and has been estimated to

be five to six times greater than for nongravid, nonpuerperal women (11).

There are no prospective series of the use of prophylactic anticoagulation in patients

undergoing surgery during pregnancy However, some investigators (11,14) have

advo-cated the use of low-dose heparin (which does not cross the placenta) in pregnant womenwho have a history of thromboembolism

The gastrointestinal tract also undergoes alterations during pregnancy Progesterone

inhibits gastric and intestinal motility and relaxes the gastroesophageal sphincter (10).

In addition, the gravid uterus displaces the abdominal contents upward toward the phragm, which may compromise the competence of the gastroesophageal sphincterfurther It has also been shown that a delay in gastric emptying begins as early as 8 to 11

dia-wk gestation (15) and that placental secretion of gastrin, which starts in the first ter, lowers the pH of gastric secretions (10) All of these factors contribute to an increased

trimes-risk of perioperative aspiration in the pregnant patient

Important physiological changes are also known to occur throughout the urinary tractduring pregnancy The renal calyces, pelves, and ureters dilate significantly beginning

Chapter 1 / Urological Problems in Pregnancy 3

in the first trimester (16) The cause of the dilation is probably both humoral and mechanical Hsia and Shortliffe (17) have also demonstrated in an animal model that

hydronephrosis in pregnancy may be the result of increased urinary tract compliance

Schulman and Herlinger (18) reviewed 220 excretory urograms performed during

preg-nancy and found the right side to be the more dilated side in 86% of the cases The relativeurinary stasis that occurs may explain why pregnant women have a higher incidence ofpyelonephritis associated with bacteriuria than nonpregnant females

Other renal changes that occur include a 30 to 50% increase in glomerular filtration

rate and renal plasma flow during pregnancy (10) Therefore, normal ranges for serum

creatinine and blood urea nitrogen are about 25% lower during gestation Because of theincrease in renal hemodynamics, medications administered in the perioperative settingmay undergo rapid urinary excretion and dosage adjustment may, therefore, becomenecessary In addition to upper tract changes, pregnancy causes changes in the bladderand urethra Pregnancy induces a significant (greater than 50%) decrease in the contrac-

tile response of the rabbit bladder to phenylephrine (19) The increased compliance and

decreased responsiveness to α-adrenoceptor stimulation of both bladder neck and thra that occurs during pregnancy may explain the stress urinary incontinence associated

ure-with pregnancy (20–22) The physiological alterations observed in pregnancy and their impact in the surgical patient are outlined in Table 1 (23,24).

ACUTE ABDOMEN AND SURGICAL CONSIDERATIONS DURING PREGNANCY

Table 1 Physiological Changes of Pregnancy

System Change Clinical implications

Cardiovascular Uterine compression of vena cava Decreased cardiac output

Increase in venous stasis in lowerextremities

Respiratory Decrease in FRC; Increase in Increased risk of perioperative

oxygen consumption hypoxemiaHematologic Increase in clotting factors and Increased rate of thromboembolism

hypercoagulabilityGastrointestinal Decreased gastric motility and Increased risk of aspiration

reduced competency ofgastroesophageal sphincter

Renal Dilation of collecting system; Increased risk of pyelonephritis

Increase in glomerular filtration Changes in renal clearance ofrate some drugs

Modified from Barron (10) and Loughlin (24).

FRC, functional residual capacity.

4 Loughlin

surgery (1 in 1500 to 6600 deliveries; refs 26,27) followed by intestinal obstruction (1 in 2500 to 3500 deliveries; ref 28) and cholecystitis (1 in 1000 to 10,000 deliveries; refs 25,29) Drago et al (30) reviewed their own experience and others in the literature

and found the incidence of urolithiasis in pregnancy to be 1 in 1500 deliveries, which

is the same as in the nonpregnant female

However, pregnancy-specific causes of abdominal pain during pregnancy are muchmore common than the aforementioned problems For example, ectopic pregnancyoccurs in every 1 in 300 pregnancies; placental disruption occurs in every 1 in 100

pregnancies (31).

Smoleniec and James (32) have emphasized that two important clinical effects of

increased uterine growth during pregnancy are the displacement of the appendix upwardabove the iliac crest and the separation of the viscera from the anterior abdominal wall,which may result in a decrease of somatic pain These factors can make the evaluation

of the acute abdomen during pregnancy extremely treacherous Silen (33) pointed out

that as a consequence of the cephalad displacement of the appendix, cholecystitis, rightpyelonephritis, and appendicitis may be extremely difficult to differentiate during preg-nancy The optimal time to perform nonobstetrical surgery during pregnancy appears to

be the second trimester There is an increased risk of miscarriage during the first

trimes-ter (25,34) and an increased risk of premature labor during the last trimestrimes-ter (34).

ANESTHETIC CONSIDERATIONS DURING PREGNANCY

The goal of anesthetic management of the pregnant patient is maternal safety and fetalwell-being Gestation is associated with a decrease in drug requirements for both general

and regional anesthesia Palahniuk and associates (35) have reported a 25 to 40%

reduc-tion in minimal alveolar concentrareduc-tions by using halothane and isoflurane during ovinepregnancy This is most likely because of the sedative effects of progesterone and the

increased levels of endogenous opiates (36,37).

The requirement for local anesthetics is also reduced early in the first trimester of

pregnancy (38) Progesterone induced enhancement of membrane sensitivity to local anesthetics has been proposed as the most likely mechanism for this observation (39).

Further decreases in drug requirements for spinal or epidural anesthesia occur withadvancing gestation because epidural venous engorgement reduces the volume of cere-brospinal fluid and the epidural space This vascular engorgement also increases the risk

of unintended intravascular injection of local anesthetic

Diazepam should not be given during pregnancy because two retrospective studieshave demonstrated an association between maternal diazepam use and occurrence of

cleft lip and/or palate in their progeny (40,41).

URINARY TRACT INFECTIONS AND ANTIBIOTIC USE DURING PREGNANCY

The prevalence of bacteriuria among pregnant women has been published as ranging

from 2.5 to 11% (42) with most investigators reporting a prevalence between 4 to 7%

(43) This is similar to the prevalence of bacteriuria among other sexually active women

of childbearing age Recurrent episodes of bacteriuria are more common among

preg-nant women who have bacteriuria documented at their initial prenatal evaluation (44).

Unfortunately, the presence of symptoms traditionally associated with urinary tractinfections has a low predictive value for identifying pregnant women with bacteriuria