Urinalysis: case presentations for the primary care physician

Urinalysis is useful in diagnosing systemic and genitourinary conditions. In patients with suspected microscopic hematuria, urine dipstick testing may suggest the presence of blood, but results should be confirmed with a microscopic examination. In the absence of obvious causes, the evaluation of microscopic hematuria should include renal function testing, urinary tract imaging, and cystoscopy. In a patient with a ureteral stent, urinalysis alone cannot establish the diagnosis of urinary tract infection. Plain radiography of the kidneys, ureters, and bladder can identify a stent and is preferred over computed tomography. Asymptomatic bacteriuria is the isolation of bacteria in an appropriately collected urine specimen obtained from a person without symptoms of a urinary tract infection. Treatment of asymptomatic bacteriuria is not recommended in nonpregnant adults, including those with prolonged urinary catheter use.

Testicular torsion: diagnosis, evaluation, and management

Testicular torsion is a twisting of the spermatic cord and its contents and is a surgical emergency affecting 3.8 per 100,000 males younger than 18 years annually. It accounts for 10% to 15% of acute scrotal disease in children, and results in an orchiectomy rate of 42% in boys undergoing surgery for testicular torsion. Prompt recognition and treatment are necessary for testicular salvage, and torsion must be excluded in all patients who present with acute scrotum. Testicular torsion is a clinical diagnosis, and patients typically present with severe acute unilateral scrotal pain, nausea, and vomiting. Physical examination may reveal a high-riding testicle with an absent cremasteric reflex. If history and physical examination suggest torsion, immediate surgical exploration is indicated and should not be postponed to perform imaging studies. There is typically a four- to eight-hour window before permanent ischemic damage occurs. Delay in treatment may be associated with decreased fertility, or may necessitate orchiectomy.

Assessment of asymptomatic microscopic hematuria in adults

Although routine screening for bladder cancer is not recommended, microscopic hematuria is often incidentally discovered by primary care physicians. The American Urological Association has published an updated guideline for the management of asymptomatic microscopic hematuria, which is defined as the presence of three or more red blood cells per high-power field visible in a properly collected urine specimen without evidence of infection. The most common causes of microscopic hematuria are urinary tract infection, benign prostatic hyperplasia, and urinary calculi. However, up to 5% of patients with asymptomatic microscopic hematuria are found to have a urinary tract malignancy. The risk of urologic malignancy is increased in men, persons older than 35 years, and persons with a history of smoking. Microscopic hematuria in the setting of urinary tract infection should resolve after appropriate antibiotic treatment; persistence of hematuria warrants a diagnostic workup. Dysmorphic red blood cells, cellular casts, proteinuria, elevated creatinine levels, or hypertension in the presence of microscopic hematuria should prompt concurrent nephrologic and urologic referral. The upper urinary tract is best evaluated with multiphasic computed tomography urography, which identifies hydronephrosis, urinary calculi, and renal and ureteral lesions. The lower urinary tract is best evaluated with cystoscopy for urethral stricture disease, benign prostatic hyperplasia, and bladder masses. Voided urine cytology is no longer recommended as part of the routine evaluation of asymptomatic microscopic hematuria, unless there are risk factors for malignancy.

Prostatitis: diagnosis and treatment

Prostatitis ranges from a straightforward clinical entity in its acute form to a complex, debilitating condition when chronic. It is often a source of frustration for the treating physician and patient. There are four classifications of prostatitis: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic. Diagnosis of acute and chronic bacterial prostatitis is primarily based on history, physical examination, urine culture, and urine specimen testing pre- and post-prostatic massage. The differential diagnosis of prostatitis includes acute cystitis, benign prostatic hyperplasia, urinary tract stones, bladder cancer, prostatic abscess, enterovesical fistula, and foreign body within the urinary tract. The mainstay of therapy is an antimicrobial regimen. Chronic pelvic pain syndrome is a more challenging entity, in part because its pathology is poorly understood. Diagnosis is often based on exclusion of other urologic conditions (e.g., voiding dysfunction, bladder cancer) in association with its presentation. Commonly used medications include antimicrobials, alpha blockers, and anti-inflammatory agents, but the effectiveness of these agents has not been supported in clinical trials. Small studies provide limited support for the use of nonpharmacologic modalities. Asymptomatic prostatitis is an incidental finding in a patient being evaluated for other urologic problems.

Screening and management of prostate cancer in elderly men: the Iowa Prostate Cancer Consensus

OBJECTIVES

The issue of prostate cancer screening and management is likely to assume greater importance with progressive aging of the population. Because there are no currently established guidelines for screening and management of prostate cancer in elderly men (older than 75 years), a multidisciplinary panel was convened to develop consensus recommendations.

METHODS

The panel consisted of experts in urology, internal medicine/geriatrics, medical oncology, radiation oncology, family practice, law, patient advocacy and physician assistants. Four internationally known experts on prostate cancer served as external advisors. Relevant literature was reviewed and consensus was developed based on expert opinion, given the lack of level I evidence regarding most aspects of prostate cancer diagnosis and management in men older than 75 years of age.

RESULTS

On the basis of the opinions of the expert panel, recommendations for screening and management of prostate cancer in elderly men older than 75 years of age was developed. In general, there was support for using greater discretion in screening for prostate cancer in elderly men. The lack of adequate patient education tools to facilitate discussion with patients was recognized. There was also agreement on the need for greater and renewed patient counseling regarding benefits and risks of prostate cancer screening beyond age 75.

CONCLUSIONS

It is possible to build consensus around a standardized approach to prostate cancer screening and management in older men. Promulgation of such consensus recommendations and their widespread adoption may help engender a tailored approach to managing prostate cancer in older men, thereby decreasing health care costs and morbidity while limiting unnecessary therapy.

Incontinence surgery in the older woman

PURPOSE OF REVIEW

To review recently published studies on stress urinary incontinence surgery outcomes in older women.

RECENT FINDINGS

Five prospective and two retrospective studies were identified that reported tension-free vaginal tape (n = 6), colposuspension (n = 1) and cadaveric fascia transvaginal sling (n = 1) procedure results. In each study, 21-175 older women were included, with mean ages ranging from 71 to 83 years; most studies included younger comparison groups. Mean follow-ups ranged from 3 to 30 months. Subjective stress urinary incontinence 'cure/improvement' rates after surgery were significantly lower in older women when compared with younger women in only one study, although similar trends were seen in two additional studies. Intraoperative complications occurred at similar rates in older and younger women. Postoperative complications (urinary tract infection, urgency, voiding dysfunction, and mesh erosion) were more common in older women in only a few studies.

SUMMARY

Recent studies demonstrate that surgery for stress urinary incontinence in older women improves symptoms, although in some reports, not to the extent seen in younger women. It is unclear if some postoperative complications are more common in older women undergoing incontinence surgery. Results from randomized trials focusing on stress urinary incontinence surgery in older women are needed.

Practice patterns in screening and management of prostate cancer in elderly men

OBJECTIVES

To determine the practice preferences for prostate cancer screening and treatment in men 75 years of age or older among healthcare providers in Iowa.

METHODS

Practice patterns were determined by an institutional review board-approved 15-item survey mailed to all 3105 Iowa healthcare providers who care for older men. A modified Dillman method was used for the survey. Actual prostate-specific antigen (PSA) testing practices derived from our institutional database were correlated with the survey data.

RESULTS

The survey yielded a response rate of 32% (997 respondents). Of the respondents, 96% of primary care physicians and 97% of urologists preferred to stop PSA-based prostate cancer screening by age 80. This was compatible with our institutional data that indicated a PSA testing rate of 5.2% in men 80 years or older. Most physicians used the digital rectal examination as the first test for screening and reported a lack of educational materials to provide to patients. Older physicians and family practitioners were more likely to continue prostate cancer screening beyond 75 years, and most consented to patient requests for screening.

CONCLUSIONS

The predilection for prostate cancer screening among healthcare providers declines with increasing patient age but persists for a small proportion of patients. The education of both patients and healthcare providers to more selectively screen men older than 75 years and the development of educational materials are needed. A consensus among healthcare providers would facilitate adoption of a tailored approach to managing prostate cancer in older men, thereby decreasing healthcare costs and morbidity while limiting the use of unnecessary therapy.

Use of bipolar power source for transurethral resection of bladder tumor in patient with implanted pacemaker

Patients with implanted electrical devices such as cardiac pacemakers and cochlear implants typically must have the device inactivated before surgical procedures in which the use of electrocautery is possible. In situations in which the patient cannot tolerate inactivation of the device even for a short while, the use of a bipolar energy source may allow performance of the procedure without inactivating the device. We report the case of a patient who underwent transurethral resection of a bladder tumor using a bipolar energy source uneventfully despite the presence of an implanted cardioverter defibrillator that was not deactivated before resection.