Conditions
Urinary Stone Disease
by Julie Chacko, M.D.
• Definition: Stone(s) in the kidney.
• Overview:
· Kidney stones are slightly more common in men than in women. …..
• Types:
Calcium containing stones
Uric Acid Stones
Infection related stones
Cystine stones
Matrix stones
medication related stones
• Symptoms:
· May be asymptomatic (without symptoms) if the stone remains in the kidney.
· The symptoms usually occur when the stone tries to pass or blocks a portion of the kidney.
· Classic symptoms of stone passage include:
· flank pain
· nausea
· vomiting
· blood in the urine
• Etiologies:
· The causes of kidney stones are varied
· Over 90% of stone-forming patients can be found to have a clear etiology when work-up is performed.
· Urinary factors include low urinary volumes, high urinary calcium, low urinary citrate, high urinary oxalate, high urinary uric acid levels, and others.
· Other causes of kidney stones include hyperparathyroidism, cancer that has spread to the bones, treatment for cancers with chemotherapy, sedentary lifestyle (wheelchair or bed-bound patients), certain medications, urinary obstruction, hereditary causes, bowel diseases, and congenital abnormalities of the kidneys.
• Complications:
· Kidney infection can cause a serious condition known as obstructive pyelonephritis.
· Calyceal rupture can occur and is more common with small stones.
• Clinical Findings/signs:
· Blood is usually present in the urine, microscopically or sometimes visibly.
· Tenderness of the involved flank on examination.
· CT scan, ultrasound, or plain x-ray may be ordered to confirm the diagnosis.
• Treatment:
· Lifestyle: Modifications in diet can help modify the risk of recurrent stones. The work-up can be complicated and the recommendations are generally made based upon the findings of urine collection. General recommendations for calcium stone forming patients include increase in fluid intake to approximate 2-3 liters of urine a day, decreasing salt intake, and decreasing animal protein intake. Low oxalate diets may be recommended for certain patients.
· Medications used include: potassium citrate, thiazide diuretics, allopurinol, magnesium
Read more – April 16, 2009
Hematuria
by Julie Chacko, M.D.
• Definition:
· Hematuria is defined as blood in the urine.
· Gross hematuria refers to blood that is visible with the naked eye while microscopic hematuria refers to blood that is seen only when the urinary sediment is examined under the microscope.
• Overview:
· It is generally accepted that gross hematuria always warrants a work-up while that is not always the case with microscopic hematuria.
· Microscopic hematuria is generally considered significant when there are three or more red blood cells per high power field in the urinary sediment in at least two of three urine samples.
· There is no current recommendation for routine urine testing to screen for hematuria.
· There are many causes for hematuria as the blood can come from any source in the urinary tract including the kidneys, ureters, bladder, prostate or urethra.
· A few of the more common benign etiologies include but are not limited to the following: enlargement of the prostate (BPH), bladder infection, kidney infection, kidney stone, bladder stone, abnormal blood vessels, kidney diseases, history of radiation therapy and trauma to the urinary tract.
· Tumors, both benign and malignant, of the urinary tract are the more concerning causes of hematuria and the reasoning behind the complete work-up.
· There are situations in which there appears to be blood in the urine that is not in fact concerning such as menstrual bleeding or in patients who have difficulty collecting a true “midstream, clean-catch” sample.
· Blood thinning medications in and of themselves often make hematuria present or worse but are not considered an etiology and therefore most patients on blood thinning medications will be worked up in the same manner as those not on such medications.
• Types: Gross vs. Microscopic as described above.
• Symptoms:
· Hematuria in itself is generally asymptomatic with the exception of when it is heavy enough to clot and cause obstruction of the urinary tract with which patients may experience pain in the flank similar to passing a kidney stone (if the bleeding is from the kidney) or difficulty emptying the bladder if a clot obstructs the outflow of the bladder.
· Difficulty emptying the bladder may worsen to the point of urinary retention (inability to urinate).
· Depending upon the cause of the hematuria, for which there are many, the associated symptomatology varies from no symptoms at all to pain or other symptomatology severe enough to make a patient go to the Emergency Department.
• Complications:
· Hematuria can cause obstruction of the urinary tract as mentioned above.
· If very heavy hematuria occurs or prolonged microscopic hematuria persists, anemia can develop.
• Clinical Findings/signs:
· The signs and symptoms of hematuria vary depending on the cause.
· Blood in the urine is the sign.
• Treatment:
· Hematuria is a sign and not in itself a disease therefore it requires a work-up to determine the cause of the bleeding following which treatment of the underlying disease is the ultimate goal.
· When gross hematuria is causing urinary retention or clot colic (kidney pain) measures may be taken including irrigation of the bladder and admission to the hospital for monitoring and management of the bleeding and any associated complications from the bleeding.
· Work-Up: To find the source of the bleeding the patient generally will undergo some form of imaging of the kidneys (ultrasound, CT scan or other study) as well as testing of the urine and a cystoscopy (camera inspection of the bladder). Cystoscopy is generally performed in the doctor’s office and is well-tolerated with local analgesia. The camera is introduced down the urethra and the bladder is inspected for any stone, tumor or other etiology. It is generally a fairly quick procedure and once performed the mild burning on urination will resolve within two urinations or 24 hours.
• Prognosis:
· Hematuria is a sign and not a disease therefore prognosis depends upon the underlying etiology that is discovered when the work-up is performed.
Non-Bacterial Prostatitis
by Julie Chacko, M.D.
• Definition: Inflammation of the prostate that is not due to infection.
• Overview:
· This syndrome should be distinguished from prostatodynia which is prostatic pain without evidence of inflammation or infection.
· Non-bacterial prosatitis is more common than bacterial prostatitis and can be far more bothersome for patients.
· The cause of chronic non-bacterial prostatitis is unknown.
• Types:
· This is distinct from acute bacterial prostatitis, chronic bacterial prostatis and prostatodynia.
• Symptoms:
· The symptoms are similar to chronic bacterial prostatitis with episodic or sometimes low-level chronic pain in the perineum between the scrotum and anus, low back, low abdomen and with ejaculation. Burning with urination and discomfort in the penis may be present.
• Complications:
· There usually are not complications associated with this diagnosis though patients with chronic pain can develop depression or anxiety related to the chronic pain syndrome.
• Clinical Findings/signs:
· The prostate is sometimes tender on examination.
· Prostate massage to obtain expressed prostatic secretions (EPS) or the urine collected after massage should demonstrate white cells indicative of the inflammation but the culture of that fluid should not grow any organism.
· There are few other physical signs or symptoms.
• Treatment:
· Lifestyle: If ejaculation is not painful, regular ejaculation may help to relieve symptoms in some patients. Stress reduction and warm baths (submerging the prostate area) can be helpful for some.
· Medication: Many patients are treated initially with antibiotics until it is clear that the symptoms are not infection-related. Antibiotics aimed at less common organisms may also be tried in an effort to define the condition. Antibiotics aimed at less common organisms may also be tried in an effort to define the condition. Once clear that there is no infection present, medications to relieve symptoms can be used and may include any of the following: anti-inflammatory medications, Flomax* or other alpha-blocker medications, anti-spasmodics for the bladder and urinary analgesic medications such as Pyridium* or Prosed*. Some patients may benefit from referral to a pain management specialist if symptoms are severe.
· Surgery: No clear indication for surgical intervention with this disease.
• Prognosis:
· Prognosis is fair.
· Many patients learn lifestyle modifications that help to control and alleviate symptomatology but this is generally a chronic condition that results in intermittent or chronic symptoms for many.
Chronic Bacterial Prostatitis
by Julie Chacko, M.D.
• Definition: Recurrent or persistent bacterial infection of the prostate gland.
• Overview:
· This is the most common source for recurrent urinary track infection (UTIs) in men.
· The most common organism being E. Coli.
• Causes:
· Incomplete treatment of an episode of acute bacterial prostatitis can contribute to the onset of chronic bacterial prostatitis.
· Often there are calcifications within the prostate that harbor the organism and prevent complete clearance with antibiotics.
• Symptoms:
· The typical symptoms include burning with urination, frequency of urination and pain in any number of areas including the low back, perineum (between the anus and scrotum), low abdomen and increased pain with ejaculation.
· Patients with chronic bacterial prostatitis tend not to be as acutely ill as those with acute prostatitis and fever, lethargy and fatigue are usually not present.
• Complications:
· The recurring infections can lead to fertility issues and occasionally to prostatic abscess formation.
• Clinical Findings/signs:
· The prostate is tender on examination.
· Prostatic massage may be performed to try to obtain a specimen from the prostate itself.
· If a drop of fluid is obtained from the prostate (EPS) or the urine immediately after massage is collected, it usually demonstrates elevated numbers of white cells and will be positive for an organism when cultured.
· PSA (prostate specific antigen) blood test will usually be elevated as well.
• Treatment:
· Lifestyle: There are no lifestyle modifications to treat chronic bacterial prostatitis.
· Medication: The primary treatment is antibiotic therapy for a prolonged course, often 3-6 months, in an effort to eradicate infection. During the treatment course anti-inflammatory medications may be useful in controlling pain related symptoms. If burning on urination is present, bladder analgesics such as Prosed* or Pyridium* may be prescribed.
· Surgery: Surgical management is rarely indicated for chronic bacterial infection. Transurethral resection of the prostate can be performed in an effort to remove prostatic calculi but may not be successful in eradicating infection.
• Prognosis:
· Clearance of the infection can be difficult.
· The prognosis depends on whether clearance of infection is attainable.
· If not, persistent symptomatology is the norm and frequency and control of symptoms is variable.
Acute Bacterial Prostatitis
By Julie Chacko, M.D.
• Definition: Bacterial infection of the prostate gland.
• Overview:
· Tends to be diagnosed in younger men.
• Types:
· Acute bacterial prostatitis is one of a number of inflammatory conditions that can affect the prostate. See Chronic Bacterial Prostatitis and Non-bacterial prostatitis as well.
• Symptoms:
· Usually presents with fever, urinary frequency or urgency, pain with ejaculation, discomfort in the perineum (the area between the back of the scrotum and anus), and may have associated general fatigue.
· There may be associated difficulty emptying the bladder which may be perceived due the the irritative symptoms or actual due to obstruction of urinary flow due to the swollen gland.
• Complications:
· Bacteremia (infection spreading into the bloodstream) is a possible complication which, if not treated promptly, can result in sepsis.
· Prostatic abscess can form even when treated with appropriate antibiotics.
• Clinical Findings/signs:
· Fever is generally present.
· The prostate is warm and tender on examination.
· Bloodwork reveals an elevation in the white blood cell count as well as the PSA if it is checked during infection.
· The most common organism is E. Coli and the organism can be cultured from the seminal fluid and usually from the urine as well.
· When the infection has spread to the bloodstream blood cultures will also be positive.
· Imaging is usually not necessary to make the diagnosis though a CT or prostate ultrasound may be ordered if the clinical course warrants further evaluation.
• Treatment:
· Lifestyle: There is no lifestyle modification that can treat acute bacterial prostatitis though using a barrier method during anal intercourse may help reduce infection rates.
· Medication: Antibiotics are the mainstay of treatment. Depending on the severity of infection, admission to the hospital to start IV antibiotics may initially be indicated. The antibiotics are generally taken for at least four to six weeks to ensure complete eradication of the infection. Anti-inflammatories and fever reducing agents such as Tylenol* may alleviate symptoms. Stool softeners may be helpful as well.
· Surgery: If the patient is unable to urinate, a tube may be placed through the abdomen directly into the bladder (called a suprapubic tube). Otherwise, surgical intervention in rarely indicated unless a prostatic abscess forms.
• Prognosis: Prognosis tends to be good if caught early.
Acute Pyelonephritis
by Julie Chacko, M.D.
• Definition: Infection of the kidney.
• Overview:
· More common in women than in men.
· Infection of the kidney can occur due to organisms spreading to the kidney from the bladder (ascending infection) or from the bloodstream.
· Ascending infection is more common.
· E. Coli is the most common organism.
· Abnormalities of the heart valves can be the source of organisms being spread by the bloodstream.
• Types:
· Bacterial
· Fungal
• Symptoms:
· Typically the patient experiences flank pain (pain in the back just below the ribcage), fevers and often nausea and vomiting.
· The pain can be located in the upper right abdomen as well.
· Kidney infection may or may not be accompanied by symptoms of bladder infection (see acute cystitis) and on occasion the urine will have blood that is visible.
• Complications:
· If not treated completely and in a timely manner an abscess can form in the kidney or in rare cases the infection can get into the bloodstream and make one very ill requiring hospitalization.
· If pyelonephritis develops as a patient is passing a kidney stone, immediate intervention may be necessary to decompress the kidney and allow proper drainage of the kidney for infection to clear.
• Clinical Findings/signs:
· Pyelonephritis remains a clinical diagnosis. The findings on examination include flank or upper abdominal tenderness, fever and usually a positive urine analysis and culture for bacteria. Nausea and vomiting are often present. If the bladder is infected there may be tenderness of the lower abdomen overlying the bladder as well. Imaging with ultrasound, CT or other modality can be used when there is suspicion of a stone or other complicating factor. Patients can have a wide range of symptoms including septic physiology (critically low blood pressure and unstable vital signs) if the infection has spread to the bloodstream.
• Treatment:
· Lifestyle – there are no lifestyle modifications to decrease the chances of pyelonephritis unless one is prone to recurrent bladder infections.
· Medication – Antibiotics are generally used to treat the infection. The length of time the patient is on antibiotics depends upon the specific antibiotic and the clinical situation. Though most pyelonephritis episodes can be treated on an outpatient basis, admission to the hospital may be warranted for IV antibiotics.
· Surgery: Surgical intervention may be necessary if the pyelonephritis is complicated by renal abscess or a urinary stone. The type of surgery or intervention depends upon the clinical situation. Occasionally the intervention can be performed by the radiologist without going under an anesthetic.
• Prognosis: The prognosis for acute bacterial pyelonephritis is good assuming that there is no complicating factor such as abcess, sepsis or stone. In children, whose kidneys are still developing, bacterial pyelonephritis can cause scarring of the kidney tissue and, if recurrent, can lead to overall decreased kidney function later in life.
Recurrent Cystitis
by Julie Chacko, M.D.
• Definition: Recurrent infection of the bladder.
• Overview:
· Recurrent cystitis refers to repeated infection of the bladder after the initial infection has been cleared.
· This can occur due to re-infection or due to re-population that occurs when there is a source of infection that was not cleared such as a stone.
· The situation in which there is re-population with the same organism is also referred to as bacterial persistence.
• Causes:
· Most commonly bacterial in nature and often without any clear diagnosable cause.
· Recurrent infections can be associated with:
· abnormal connections between the bowel and urinary tract (fistulas)
· immunosuppression
·poorly controlled diabetes
· prostatitis
· urinary tract stones
· sexual activity
·factors that lead to poor drainage of an area or a site in which bacteria can “hide” from antibiotics and other causes.
• Symptoms:
· Dysuria (burning during urination)
· Frequency of urination
· Urgency to urinate and often small volumes urinated
· Pain in the bladder (felt as discomfort in the lower abdomen) is often present.
· The only difference symptomatically from acute cystitis is the recurrent nature.
• Complications:
· Fever
· upper urinary tract infection (see pyelonephritis)
· hematuria (blood in the urine)
• Clinical Findings/signs:
· There may be few signs other than those of acute cystitis.
· Physical examination may reveal:
· tenderness in the kidney area if stone or kidney involvement is present
· urethral diverticuli may be discovered on physical examination of the pelvic organs.
· Depending on clinical suspicion, the work-up may include imaging of the urinary tract with
· plain x-rays, ultrasounds, or CT scans.
· if urethral diverticulum is suspected, MRI may be necessary to confirm the diagnosis.
· using a small camera to evaluate the bladder, known as cystoscopy, may also be performed to evaluate anatomy and rule out other causes for the symptoms.
• Treatment:
· Medication:
· Antibiotics are the mainstay of therapy for bacterial infection. Following treatment of the acute episode, low dose antibiotics to prevent infection may be prescribed and used daily if necessary or just after intercourse if that is the inciting event. Some patients can be given prescriptions to treat infection when it occurs rather than trying to prevent them.
· vaginal estrogen replacement In post-menopausal women can be used to help prevent recurrent infections.
· Lifestyle:
·Prevention of recurrent infection may be helped by controlling diabetes, emptying the bladder regularly and with a catheter when necessary.
· Avoiding use of spermicides and diaphragms is advised.
· Cranberry is believed to be helpful in preventing UTIs but is not likely to be effective in treating UTIs. Data available does not clearly define the dosing necessary. The active ingredient from cranberry is readily destroyed by light and heat making the amount available in any product difficult to control.
· Surgery: May be indicated to remove a kidney stone, urethral diverticulum, fistula or other anatomic abnormality that is thought to be the source. The surgery recommended is specific to the cause identified.
• Prognosis: The prognosis is generally good. Many young women “outgrow” the recurrent infection issue and can be treated effectively in the meantime. Older women can often be controlled with local estrogen replacement and prophylactic antibiotics when needed. Removal of the source of infection is generally curative for those in whom a source is identified.
Acute Cystitis
by Julie Chacko, M.D.
• Definition: Infection of the bladder
• Overview: Acute cystitis is one of the more common reasons for patient visits.
· It is one form of UTI (urinary tract infection) though cystitis more specifically refers to the bladder being the site of infection.
· Approximately 90% of infections can be cleared with a single course of antibiotics as typically the infection is a bacterial infection and the most common organism is E. Coli.
· There are factors that lead to some women being more susceptible to infection than others.
• Types of infections:
· Bacterial
· viral
· fungal
· non-infectious (see Painful Bladder Syndrome)
• Symptoms:
· Dysuria (burning during urination)
· Frequency of urination
· Urgency to urinate and often small volumes urinated
· Pain in the bladder (felt as discomfort in the lower abdomen) is often present
• Complications:
· Fever
· Upper urinary tract infection (see pyelonephritis)
· Hematuria (blood in the urine)
• Clinical Findings/signs: Generally very few signs are found on physical examination.
· Tenderness just above the pubic bone, overlying the bladder, can sometimes be appreciated.
· Diagnosis is made preliminarily based on history and urinalysis and confirmed when indicated by a positive culture result.
· Fungal and viral infections are relatively rare and may be missed on the urine initial culture.
• Treatment:
Medication:
· Antibiotics are the mainstay of therapy for Bacterial infection.
· Urinary agents that help to relieve the burning sensation are often used as well but do not by themselves treat the infection.
· Antispasmodics for the bladder can also be prescribed for symptomatic control if severe.
Lifestyle:
· Prevention of infection is believed to be aided by proper hygiene (wiping oneself from front to back therefore moving the fecal organisms away from the urethra)
· Adequate fluid intake and bladder emptying.
· Post-Coital (after intercourse) urination helps to clear bacteria as well.
· Surgery: rarely indicated except in rare circumstances of recurrent infection.
• Prognosis: Excellent.
· Symptoms generally begin to resolve within 1-2 days though may last longer than the course of antibiotics due to residual inflammation.
· This residual inflammation should resolve within 5-7 days though can last longer.
· Repeat culture may be indicated to check if the organism was sensitive to the prescribed antibiotic if resolution does not occur quickly.
Low Libido – Male
Coming soon…
Low Libido – Male
Definition:
Overview:
Types:
Symptoms:
Complications:
Clinical Findings/signs:
Treatment:
Lifestyle
Medication
Surgery
Prognosis:
References:
Read more – April 15, 2009
Male Infertility
Coming soon …
Male Infertility
Definition:
Overview:
Types:
Symptoms:
Complications:
Clinical Findings/signs:
Treatment:
Lifestyle
Medication
Surgery
Prognosis:
References:
