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Caner Z. Dinlenc, MD
Harris M. Nagler, MD
Sovrin M. Shah, MD
KIDNEY STONES
URINARY TRACT INFECTIONS (UTI)
BENIGN PROSTATIC HYPERPLASIA (BPH)
URINARY INCONTINENCE
HEMATURIA
KIDNEY STONES
The kidneys function as a filter for the body, removing waste products
from the bloodstream and then removing them from the body in the form
of urine. Kidney stones are a buildup of mineral waste deposits in the
kidney not removed by urination. Stones can form for numerous reasons,
such as an imbalance in the chemical composition of urine, inadequate
fluid consumption, poor diet (one high in fats, sodium, sugars), blocked
or restricted urine flow, or certain diseases (i.e., gout, colitis, arthritis).
Stones begin in the kidney and may either stay there or slowly pass down the ureter (the tube connecting the kidney to the bladder) to reach the bladder before passing through the urethra (the canal through which you urinate). Stones that are small and have a smooth exterior may show no symptoms and may pass unknowingly, but stones that are larger or have a rough exterior may lodge on their way out of the body.
Symptoms
- Slight or severe pain when urinating
- Blood in the urine (hematuria)
- Pain in the kidney (flank), groin or abdomen
- Recurrent urinary tract infections
Treatment
Patients with kidney stones have a number of options, with treatment depending
on the size of the stone, its cause, and whether they are an isolated
occurrence or recurring. In cases where it will not cause further complications,
the stone is allowed to pass naturally by urination, and is collected
for examination to determine its cause.
Other options for treatment are:
- Changes in diet or fluid intake
- Decreasing or increasing intake of certain vitamins
- Medications
- Extracorporeal Shock Wave Lithotripsy (ESWL), a non-surgical alternative to stone removal. Shockwave technology locates the stones and crushes or fragments them into fine particles. Patients may then pass the stone fragments naturally with little discomfort.
- Minimally invasive surgery for unusually large stones that cannot be broken up by ESWL.
URINARY TRACT INFECTIONS (UTI)
Often called cystitis which means inflammation of the bladder,
urinary tract infections generally involve the bladder and rarely ascend
(go upward) to involve the kidney where it is called pyelonephritis.
Symptoms
- Frequent urination
- Urgency (constant need to urinate)
- Dysuria (pain when urinating)
- Small volumes when urinating
- Hematuria (blood in the urine)
- Fever and/or flank/back pain
Causes and Treatments
The initial treatment for a urinary tract infection is antibiotics for
3-10 days, on average. If you have recurrent infections, treatment will
depend upon the cause of the recurrent infections. There are multiple
causes of UTI, depending on the age of the patient and/or their sex, with
the primary causes listed below:
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With patients that have retained urine because of obstruction, treatment is aimed at relieving the obstruction. Patients that have urethral strictures can have these dilated or incised. If the obstruction is due to BPH, patients may have TURP (trans-urethral resection of the prostate), TUNA (trans-urethral needle ablation of prostate), or open surgical procedures. |
BENIGN PROSTATIC HYPERPLASIA (BPH)
Benign Prostatic Hyperplasia, also called 'enlarged prostate' is generally
found in men over the age of 50. In fact, nearly all men over the age
of 50 have an enlarged prostate to some degree, but not all of these cases
require treatment. The prostate is located under the bladder in men and
behind the pubic bone. It partially surrounds the urethra and is responsible
for many of the lower urinary tract problems experienced in men as it
enlarges with age.
Symptoms
- Frequency of urination, nocturia (frequency at night)
- Urgency (desire to void again within a short time of urinating)
- Hesitancy (waiting some time to initiate the stream)
- Decreased force of urinary stream
- Intermittency (a stop-start pattern in urinating)
- Feeling of incomplete emptying (urine remaining in the bladder after
urinating)
Diagnosis
On occasion, patients may develop similar symptoms due to prostatitis
(inflammation of the prostate), primarily from infection that is treated
with antibiotics. To determine if these symptoms are due to BPH, patients
may be evaluated with:
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Treatment
Once it is determined that your symptoms are associated with BPH, treatment
will depend on the severity of these symptoms. Treatments are either medical
(non-surgical) or surgical.
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Surgical treatments for BPH vary from TURP (transurethral resection of the prostate), to minimally invasive procedures such as TUNA (Transurethral Needle Ablation), ILTT (Indigo Laser Thermotherapy), Microwave Therapy, WIT, or Prostatic Stents. While TURP removes tissue, the minimally invasive techniques employ the use of energy to heat the prostate, and time to allow the prostatic channel to open so that urinary flow is improved.
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URINARY INCONTINENCE
Incontinence is defined as the involuntary loss of urine (i.e. leaking
urine when one is not urinating). There are generally 4 different types
of urinary incontinence:
- Stress incontinence describes the loss of urine associated
with ‘stress’ placed on the bladder and pelvic floor muscles
such as exercise, coughing, laughing, sneezing and/or sexual intercourse.
- Urge incontinence describes the loss of urine with a sudden desire to void that cannot be restrained. Fluid intake, spicy foods, infection, and/or any irritant in the bladder (i.e. stone, polyp) may initiate this.
- Mixed incontinence incorporates aspects of both stress and urge as described above.
- Overflow incontinence is seen in patients that have poorly contractile bladders (i.e. Diabetes, Neurologic disoders) or bladder outlet obstruction (BPH, urethral stricture, prolapse bladder/uterus)
Diagnosis
After a complete history and physical, there are many tests that are used
to diagnose the type of incontinence, and how to treat it. These tests
include:
- Urine studies can be used to determine underlying conditions such as infections, hematuria, diabetes, or cancer.
- Uroflow involves urinating into a computerized commode to determine the volume, speed and method of urinating.
- Urodynamics documents bladder function and incontinence by using a computer to assess bladder activity while it is being filled and while one is urinating.
- Cystoscopy to evaluate the bladder walls for possible polyps, stones or chronic infection.
Treatment
Using the above information, treatment for urinary incontinence may involve:
- Behavior modification involves diet, fluid intake, voiding schedules, pelvic floor excercises/biofeedback for patients with stress, urge or mixed incontinence.
- Medication is aimed at either the bladder (i.e. Detrol®, Ditropan®) or at the prostate (i.e. Flomax®, Hytrin® or Proscar® for patients with urge or overflow incontinence.
- Surgery may be used to support the urethra/bladder for patients with stress incontinence (i.e. Pubovaginal Sling, TVT, Collagen injection) or to relieve the obstruction in patients with enlarged prostates (i.e. TURP, TUNA), urethral strictures or pelvic prolapse.
- Catheterization may be used temporarily or permanently for patients with overflow incontinence who are either beginning medical therapy or awaiting surgery.
HEMATURIA
Hematuria is defined as blood in the urine that is either seen or unseen
(microscopic). When it is detected microscopically, it may be defined
as trace, small, moderate or large depending on the number of red blood
cells that are seen under the microscope.
There are many causes of hematuria, such as:
- Urinary Tract Infections (UTI)
- Kidney Stones- Movement of a kidney stone can irritate the lining of the kidney, ureter, bladder or urethra and cause hematuria. During movement of the stone, there may be flank pain.
- Atrophic Vaginitis, which is seen in many women after menopause. Lack of local estrogen causes the vaginal/urethral tissues to be come dry and less flexible. Patients may complain of dyspareunia (pain with sexual intercourse). Lack of moisture causes the tissues to break easily, and bleeding can occur.
- Renal Diseases, which can also be termed glomerulonephritis and include a host of medical conditions that effect the filtering properties of the kidney, such that red blood cells escape into the urine. Many times these conditions require no treatment, but other times medication is needed. Nephrologists (kidney specialists) are generally involved in evaluating and treating patients with the above findings.
- Cancer that occurs in the kidney, ureter, bladder, prostate or urethra may cause hematuria either with or without pain.
Diagnosis
To determine the cause of hematuria, several tests are used:
- Urine Culture is generally done at the time of the urinalysis to determine if there is an infection.
- Urine Cytology is a urine test that looks at the shapes of the cells in the urine to determine if they are normal or abnormal, and is useful in detecting some cancers.
- Renal Ultrasound is a non-invasive test done by a radiologist to evaluate the kidneys. By using an ultrasound probe that is pressed along the flank/back over the kidney, images of the kidney are seen. This can detect hydronephrosis (swelling), kidney stones, scarring (due to prior infections), or masses.
- IVP (Intravenous Pyelogram) uses an iodine dye, given intravenously, in order to visualize the kidneys and ureters and determine their function. Patients that are allergic to iodine contrast or shellfish should alert their physician, as they may not be able to have this exam.
- CT (CAT Scan) can be done with or without contrast. It is much faster than the IVP but does hold the same restriction to iodine contrast/shellfish allergies if using contrast.
- Cystoscopy will evaluate the bladder walls for possible polyps, stones or chronic infection.
Treatment
Treatment will depend on the cause of the hematuria.
- UTI will require antibiotics.
- Kidney stones may require drug therapy, shock wave lithotripsy (used to break up the stone), or surgical removal.
- Atrophic vaginitis is often times helped with local estrogen cream.
- Renal disease is treated medically with close follow-up with a Nephrologist.
- Cancer is treated surgically, depending on the organ affected.
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