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General Questions

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In an effort to provide the highest level of patient safety and diagnostic accuracy, Middlesex Urology is now proud to offer the know error system for prostate biopsies. This unique system uses bar coding, forensic principles and DNA matching to ensure that when your test results arrive, the results belong to you.

To facilitate this process, a reference sample of DNA is taken by gently swabbing the inside of your cheek at the time of your biospy procedure. If your biopsy results come back positive for cancer (malignant), a DNA Specimen Provenance Assignment (DSPA) test is performed to compare the DNA profiles of your biopsy tissue(s) and reference sample. Concurrance of these profiles allows your physician to confirm that the biopsy results belong to you.

To learn more about the know error system for prostate biopsies, visit www.knowerrror.com

Cystoscopy

Cystoscopy, or cystourethroscopy, is a procedure that enables your urologist to view the inside of the bladder and urethra in great detail. It is used to evaluate signs and symptoms such as blood in the urine, lower urinary tract symptoms, recurrent urinary tract infections, and it can help diagnose diseases such as urethral stricures, outpouchings, or masses, prostate enlargement, bladder outpouchings, stones, lesions, or tumors.

The cystoscope is a thin tube approximately 5 to 7 mm (1/4 inch) in diameter. It can be either flexible or rigid. It has a lens, a fiberoptic light source, and a channel for irrigation to distend the bladder and urethra to allow for their visualization. It may also accommodate an instrument such as a grasper, biopsy forceps, or a cautery unit.
Cystoscopy is usually performed as an outpatient procedure in a urology clinic or treatment room. Prior to the procedure, you will need to empty your bladder. You will then be positioned on an examination table. After administration of topical anesthesia, the cystoscope is inserted into your urethra and advanced into your bladder. Water or saline is instilled into the bladder through the cystoscope. You may feel some pressure and a sensation of fullness.

Under normal conditions, your urethra is wide enough to accommodate the cystoscope, and should appear smooth, pink, and even. Your bladder wall should also appear smooth and pink, and the bladder should be of normal size and shape. If any tissue in the bladder wall appears abnormal, a small sample can be removed through the cystoscope to be analyzed.

The average cystoscopy takes about 5 minutes.
You may resume your normal daily activities after the procedure. You may feel a burning sensation or urinary frequency and urgency for up to 72 hours. Sitting in a warm tub bath and increasing your fluid intake may help relieve this discomfort. If your discomfort persists, you develop a fever greater than 101.4, you are unable to urinate, or your urine appears bright red, you should notify your physician.

There are many reasons why a person can have blood in their urine. This condition, known as hematuria, can be an indication of a serious problem or conversely, have no negative connotation. What should you do if you find out that there’s blood in your urine? Read the following to learn more.

What is hematuria?

Hematuria is defined as the presence of red blood cells in the urine. It can be characterized as either “gross” (visible to the naked eye) or “microscopic” (visible only under the microscope). Microscopic hematuria is an incidental finding often discovered on urine tests as part of a routine medical evaluation, whereas gross hematuria could prompt you to visit the doctor. Hematuria can originate from any site along the urinary tract, including the kidneys, ureters, bladder, prostate and urethra. It is estimated that hematuria occurs in 2.5 to 21 percent of the population. In many patients no specific cause is found; however, hematuria may be a marker for infection, stone disease or urinary tract cancer. Risk factors for significant underlying disease include: smoking, radiation, overuse of some pain medicines and exposure to certain chemicals.

What are the common causes of hematuria?

Blood in the urine is often not a sign of significant disease. Studies have shown that between nine to 18 percent of normal individuals can have some degree of hematuria. However, hematuria can be a sign of an important medical condition requiring treatment. Below is a list of common causes of hematuria:

  • Bladder Cancer
  • Kidney Cancer
  • Prostate Cancer
  • Ureteral Cancer
  • Urethral Cancer
  • Urinary Stone Disease
  • Urinary Tract Infection
  • Pyelonephritis (Kidney Infection)
  • Benign Prostatic Hypertrophy (Enlarged Prostate)
  • Renal (Kidney) Disease
  • Radiation or Chemical Induced Cystitis (Bladder Irritation)
  • Injury to the Urinary Tract
  • Prostatitis (Prostate Infection)
  • Exercise Hematuria

How is hematuria diagnosed?

Visible hematuria is often worrisome to the patient and prompts them to seek medical attention; however, microscopic hematuria can be just as severe. It often has no symptoms and is detected on a urine dipstick test. If the dipstick test is positive for blood the amount of blood is often determined by looking at the urine with a microscope. If three or more red blood cells (RBC) are seen per high power field on two of three specimens, further evaluation to determine a cause is recommended.

What additional tests are needed?

Any patient with gross hematuria or significant microscopic hematuria should have further evaluation of the urinary tract. The first step is a careful history and physical examination. Laboratory analysis consists of a urinalysis and examination of urinary sediment under a microscope. The urine should be evaluated for protein (a sign of kidney disease) and evidence of urinary tract infection. The number of red blood cells per high-powered field should be determined. In addition the shape of the blood cells should be evaluated. This can help determine where the bleeding is coming from. In patients with white blood cells in the urine, a urine culture should be performed as well. A urinary cytology is also obtained to look for abnormal cells in the urine. A blood test should also be done to measure serum creatinine (a measure of kidney function). Those patients with significant protein in their urine, abnormally shaped red blood cells, or an elevated creatinine level should undergo general medical evaluation for the presence of kidney disease.
A complete urologic evaluation for hematuria also includes X-rays of the kidneys and ureters to detect kidney masses, tumors of the ureters and the presence of urinary stones. This traditionally consisted of an intravenous pyelogram (IVP). In this study, a radiographic dye is injected into the blood stream and X-rays are taken as the kidneys excrete the dye. This study has trouble detecting small renal masses and is often combined with a renal ultrasound.
Many physicians may opt for other imaging studies such as a computerized tomography (CT) scan. This is the preferred method of evaluating kidney masses and is the best modality for the evaluation of urinary stones. Recently many urologists have been using CT urography. This allows the urologist to look at the kidneys and ureters with one X-ray test. In patients with an elevated creatinine or an allergy to X-ray dye, magnetic resonance imaging (MRI) or retrograde pyelography is used to evaluate the upper urinary tract. During retrograde pyelography, the patient is taken to the operating room and dye is injected up the ureters from the bladder and then images are taken.
The main limitation of these imaging studies is the inability to evaluate the bladder; therefore a cystoscopic evaluation is required. This is usually performed in the office under local anesthesia with either a rigid, or more commonly, a flexible cystoscope. After applying a topical analgesic to the urethra the urologist inserts an instrument called a cystoscope through the urethra and into the bladder. Looking through the cystoscope the doctor can examine the inner lining of the bladder and urethra for abnormalities.

What happens if no abnormality is found?

In at least eight to 10 percent of cases no cause for hematuria is found. Some studies have demonstrated an even higher percentage of patients have no cause. Unfortunately, studies have shown that urologic malignancy is later discovered in one to three percent of patients with negative work-ups. Therefore, some form of follow-up is recommended. Recommendations regarding follow-up are sparse and no clear consensus has been agreed upon. Consideration should be given to repeating the urinalysis and urine cytology at six, 12, 24 and 36 months. Immediate re-evaluation with possible cystoscopy and repeat imaging should be performed in the face of gross hematuria, abnormal urinary cytology or irritating urinary symptoms such as pain with urination or increased frequency of urination. If none of these symptoms occur within three years, no further urologic testing is needed.

How will hematuria be treated?

Treatment will be based on a physician’s evaluation of the patient’s condition, symptoms and medical history along with the cause of the hematuria.

Medical Management of BPH

Throughout a man’s life, the prostate may grow and start to cause problems as a man gets older. For many years, surgery was the only relief for this very common problem. Today, medications are the most common method for controlling urinating symptoms of BPH. What are the causes of these symptoms and what are some of the new treatments? The following should help answer that question as well as others.

What is the prostate?

The prostate, part of the male reproductive system, is about the same size and shape as a walnut and weighs about an ounce. It is located below the bladder and in front of the rectum and surrounds the urethra, the tube-like structure that carries urine from the bladder out through the penis. The main function of the prostate is to produce ejaculatory fluid.

What is BPH?

Benign prostatic hyperplasia (BPH) is a common urological condition caused by the non-cancerous enlargement of the prostate gland in aging men. Urinating symptoms can occur as the prostate enlarges.
What are some of the risk factors for BPH?
Risk factors for developing BPH include increasing age and a family history of this condition.

What are some of the symptoms associated with BPH?

Since the prostate surrounds the urethra just below the bladder, its enlargement can result in symptoms that irritate or obstruct the bladder. A common symptom is the need to frequently empty the bladder, especially at night. Other symptoms include difficulty in starting the urine flow or dribbling after urination ends. Also, size and strength of the urine stream may decrease.

How are the urinating symtoms secondary to BPH diagnosed?

In order to help assess the severity of such symptoms, the American Urological Association (AUA) BPH Symptom Score Index was developed. This diagnostic system includes a series of questions that target the frequency of the urinary systems identified above, and as a result, helps identify the severity of the BPH ranging from mild to severe.

There are a number of diagnostic test procedures that can be used to confirm BPH. The tests vary from patient to patient, but the following are the most common: digital rectal examination (DRE), PSA test, transrectal ultrasound (this measures the size of the prostate), urine flow study (this measures the speed and strength of the urinary stream), measurement of how much urine is left after urinating (post-void residual urine) and cystoscopy (a fiber-optic instrument inserted into the urethra to examine both the prostate and the urinary bladder).

What are some of the medical treatments available for BPH?

Alpha blockers: These drugs, originally used to treat high blood pressure, work by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and reduce bladder outlet obstruction. Although alpha blockers may relieve the symptoms of BPH, they usually do not reduce the size of the prostate. They are usually taken orally, once or twice a day and they work almost immediately. Commonly prescribed alpha blockers include: alfuzosin, terazosin, doxazosin and tamsulosin. Side effects can include headaches, dizziness, light-headiness, fatigue and ejaculatory dysfunction.
5-alpha-reductase inhibitors: Finasteride and dutasteride are oral medications that work completely different then alpha blockers. In select men, finasteride and dutasteride can relieve BPH symptoms, increase urinary flow rate and actually shrink the prostate though it must be used indefinitely to prevent recurrence of symptoms. Studies suggest that these medications may be best suited for men with relatively large prostate glands. It may take as long as six months to a year, however, to achieve maximum benefits from this drug. Side effects can include impotence, decreased libido and reduced semen release during ejaculation.

Frequently asked questions:

Is BPH a rare condition?

No, it is very common. It will affect approximately 50 percent of men between the ages of 51 and 60 and up to 90 percent of men over the age of 80.

Does BPH lead to prostate cancer?

No, BPH is not cancer and cannot lead to cancer, although both conditions can exist together. There are usually no symptoms during the early stages of prostate cancer, so yearly physical examinations and PSA tests are highly recommended.

Which type of drugs are the best?

To date, there is not enough research data to predict who will respond to medical therapy or which drug will be better for an individual patient.

How do I know if oral medications are the best treatment for me?

If you are diagnosed with BPH, you should discuss all treatment options with your urologist. Together, you can decide whether medication or surgical treatment is best for you.

Medical Management of Stone Disease

Kidney stones are among the most painful and prevalent of urologic disorders. More than a million kidney stone cases are diagnosed each year, with an estimated 10 percent of Americans destined to suffer at some point in their lives.

Fortunately, most stones pass out of the body without any intervention. If you are not so lucky, the following information should help you and your doctor address the causes, symptoms and possible complications created by your kidney stone disease.

What happens under normal conditions?

The urinary tract, or system, consists of the kidneys, ureters, bladder and urethra. The kidneys are two bean-shaped organs below the ribs in the back of the torso (area between ribs and hips). They are responsible for maintaining balance by removing extra water and wastes from the blood and converting it to urine. The kidneys keep a stable balance of salts and other substances in the blood. They also produce hormones that build strong bones and help form red blood cells. Urine is carried by narrow muscular tubes, the ureters, from the kidneys to the bladder, a triangular-shaped reservoir in the lower abdomen. Like a balloon, the bladder’s walls stretch and expand to store urine and then flatten when urine is emptied through the urethra to outside the body.

What is a kidney stone?

A stone forms in the kidney when there is an imbalance between certain urinary components chemicals such as calcium, oxalate and phosphate that promote crystallization and others that inhibit it.
Most common stones contain calcium in combination with oxalate and/or phosphate.
A less common type of stone is caused by infection in the urinary tract. This type of stone is called a struvite or infection stone. Much less common are the pure uric acid stones. Much rarer is the hereditary type of stones called cystine stones. Even more rare are those linked to hereditary disorders.

Who forms kidney stones?

For unknown reasons, the number of people in the United States with kidney stones has been increasing over the past 20 years. Caucasians are more prone to develop kidney stones than African Americans. Although stones occur more frequently in men, the number of women who get them has been increasing over the past 10 years, causing the ratio to change. Kidney stones strike most typically between the ages of 20 and 40. If a person forms a stone, there is a 50 percent chance they will develop another stone.

What causes a stone to form?

Scientists do not always know what makes stones form. While certain foods may promote stones in susceptible people, researchers do not believe that eating a specific item will cause stones in people who are not vulnerable. Yet they are confident that factors such as a family or personal history of kidney stones and other urinary infections or diseases have a definite connection to this problem. Climate and water intake may also play a role in stone formation.
Stones can also form because of obstruction to urinary passage like in prostate enlargement or stricture disease. Stone formation has also been linked to hyperparathyroidism, an endocrine disorder that results in more calcium in your urine. Susceptibility can also be raised if you are among the 70 percent of people with rare hereditary disorders such as cystinuria or primary hyperoxaluria who develop kidney stones because of excesses of the amino acid, cystine or the oxalate in your urine.
Another condition that can cause stones to form is absorptive hypercalciuria, a surplus of calcium in the urine that occurs when the body absorbs too much from food. The high levels result in calcium oxalate or phosphate crystals forming in the kidneys or urinary tract. Similarly, hyperuricosuria, excess uric acid tied to gout or the excessive consumption of meat products, may also trigger kidney stones.
Consumption of calcium pills by a person who is at risk to form stones, certain diuretics or calcium-based antacids may increase the risk of forming stones by increasing the amount of calcium in the urine. Calcium oxalate stones may also form in people who have chronic inflammation of the bowel or who have had an intestinal bypass operation or ostomy. This is because of loss of more water from the body as well as absorption of oxalate from the intestine.

What are the symptoms of a kidney stone?

Usually, the symptom of a kidney stone is extreme pain that has been described as being worse than child labor pains. The pain often begins suddenly as the stone moves in the urinary tract, causing irritation and blockage. Typically, a person feels a sharp, cramping pain in the back and in the side of the area of the kidney or in the lower abdomen, which may spread to the groin. Also, sometimes a person will complain of blood in the urine, nausea and/or vomiting.
Occasionally stones do not produce any symptoms. But while they may be “silent,” they can be growing, even threatening irreversible damage to kidney function. More commonly, however, if a stone is not large enough to prompt major symptoms, it still can trigger a dull ache that is often confused with muscle or intestinal pain.
If the stone is too large to pass easily, pain continues as the muscles in the wall of the tiny ureter try to squeeze the stone along into the bladder. One may feel the need to urinate more often or feel a burning sensation during urination. In a man, pain may move down to the tip of the penis. If the stone is close to the lower end of the ureter at the opening into the bladder, a person will frequently feel like they have not fully completed urination.
Stones as small as 2 mm. have caused many symptoms while those as large as a pea have quietly passed. If fever or chills accompany any of these symptoms, then there may be an infection. You should contact your urologist immediately.

How are kidney stones diagnosed?

Sometimes “silent” stones those that cause no symptoms are found on X-rays taken during a general health examination. These stones would likely pass unnoticed. If they are large, then treatment should be offered. More often, kidney stones are found on an X-ray or sonogram taken on someone who complains of blood in the urine or sudden pain. These diagnostic images give the doctor valuable information about the stone’s size and location. Blood and urine tests also help detect any abnormal substance that might promote stone formation.
If your doctor suspects a stone but is unable to make a diagnosis from a simple X-ray, he/she may scan the urinary system with intravenous pyelography (IVP). It is an imaging technique that utilizes radiopaque injections of dye followed, during excretion by the kidneys, by abdominal X-rays. A kidney obstructed by a stone will not be able to excrete the dye as quickly and may also appear enlarged when compared to the normal organ. Since this technique requires prep, it has been replaced in many hospitals by an abdominal/pelvic CT scan, an extremely accurate diagnostic tool that can detect almost all types of kidney stones painlessly.

How are kidney stones treated?

Treating kidney stone disease depends largely on the size, position and number of stones in your system. Luckily, the majority of small stones (0.2 inch or 5 mm. in diameter) that are not causing infection, blockage or symptoms will pass if you simply drink plenty of fluids each day. Consuming two to three quarts of water increases urine production, which eventually washes kidney or other stones out of the system. Once they have passed, no other treatment is necessary. The doctor usually asks one to save the passed stone(s) for testing; a cup or tea strainer can be used for this purpose.
Also, renal colic, the sudden flank pain that occurs when small stones start down the ureter, can usually be treated with bed rest and analgesics or painkillers. Certain types of stones, such as those made or uric acid, can be broken up with medical therapy. The majority, however, are composed of calcium and are not responsive to medicine.
Surgery should be reserved as an option for cases where other approaches have failed or should not be tried. Surgery may be needed if a stone:

  • does not pass after a reasonable period of time and causes constant pain
  • is too large to pass on its own
  • blocks the flow or urine
  • causes ongoing urinary tract infection
  • damages kidney tissue or causes constant bleeding
  • has grown larger (as seen as follow-up X-ray studies)

Until recently, surgery to remove a stone was very painful and required a lengthy recovery time (four to six weeks). Today, treatment for these stones is greatly improved and many options do not require major surgery.
Extracorporeal shock wave lithotripsy (ESWL®): Is the most frequently used procedure for eliminating kidney stones. It works by directing ultrasonic or shock waves, created outside your body through skin and tissue, until they hit the dense kidney stones. The stones break down into sand-like particles and are easily passed through the urinary tract in the urine. This method does not damage surrounding body tissues but breaks only the stone. The technology is only effective if the kidney is functioning well and there is no blockage to the passage of stone fragments.
In the older devices, the patient used to recline in a water bath while the shock waves were transmitted. Today, the machines are more compact and have a soft cushion on which the patient lies. Most devices use either X-rays or ultrasound to help the surgeon pinpoint the stone during treatment. For most types of shock wave lithotripsy procedures, anesthesia is not needed. In most cases, shock wave lithotripsy is done on an outpatient basis and without anesthesia. Recovery time is short and most people can resume normal activities in a few days. If the stone is about one inch in size, then more than one sitting of shock wave lithotripsy will be needed.
While shock wave lithotripsy is considered safe and effective, it can still cause complications. Most patients have blood in their urine for a few days after treatment. Bruising and minor discomfort in the back or abdomen from the shock waves are also common. To reduce the risk of complications, urologists usually tell their patients to avoid aspirin and other drugs that affect blood clotting for several weeks before treatment. Another complication may occur if the shattered stone particles cause discomfort as they pass through the urinary tract. In some cases, the urologist will insert a small tube called a stent through the bladder into the ureter to help the fragments pass.
Percutaneous nephrolithotomy (PNL): This procedure is the treatment of choice for patients with kidney stones that are larger and are in a location that does not allow effective use of shock wave lithotripsy or cause a blockage so severe that they cannot be bypassed by using a stent.
In this procedure, the surgeon makes a tiny cut in the flank area and then uses an instrument called a nephroscope to locate and remove the stone. For larger stones, a type of energy probe (ultrasonic, electrohydraulic or hydraulic) may be needed to break the stone into small pieces. All of this is done while the patient is sedated or under anesthesia.
One advantage of this procedure over SWL is that the surgeon removes the stone fragments instead of relying on its natural passage from the ureters. Generally, patients stay in the hospital two to three days and may have a small catheter in the kidney during the healing process. Most patients can resume light activity in one to two weeks.
Ureteroscopy (URS): Although some kidney stones in the ureters can be treated with shock wave lithotripsy, this procedure may be needed for mid and lower ureteral stones. In fact, this will be the preferred method in treating lower ureteral stones. Ureteroscopy involves the use of ureteroscopes, small flexible or semi-rigid telescopes that can be inserted up the urethra, through the bladder and into the ureter without an incision. These instruments allow the doctor to view a ureteral stone directly. They also have small working channels through which various devices can be passed to remove or fragment the stone. Anesthesia is generally used, and a stent is left in the ureter for a few days after treatment while healing takes place. Ureteroscopy was developed in the 1970s and came into wide use during the 1980s. Before then, a type of treatment called “blind basketing” was often used. A basket-like device was passed blindly, with no viewing instrument through the urethra and bladder and into the ureter to pull out the stone. This type of “blind” treatment risks injury to the ureter and is less effective than other methods used today. In particular, as ureteroscopy has advanced with continual instrument improvements, blind basketing is no longer a satisfactory treatment choice. The risks of ureteroscopy include perforation or stricture (scar tissue) forming, especially if the stone has been impacted or embedded within the wall of the ureter for longer than two months. The majority of ureteroscopic procedures can be performed as day surgery and that most individuals can return to work within one to two days following the procedure.

What can be expected after treatment for kidney stones?

Although stone recurrence rates differ with individuals, in general you have a 50 percent chance of redeveloping stones within the next five years. So prevention is essential. Your urologist may follow up with several tests to determine which factors e.g., medication or diet should be changed to reduce your further risk.
Do not be surprised, if you are asked to collect urine for 24 hours after a stone has passed or been removed to measure volume and levels of acidity, calcium, sodium, uric acid, oxalate, citrate and creatinine. This information will be used to determine the cause of the stone. A second 24-hour urine collection will be needed on a restricted diet to determine the causes. A third 24-hour analysis may be used to find out the effectiveness of treatment.

Frequently asked questions:

How can I prevent kidney stones?

A good first step for prevention is to drink more liquids water is the best. If you tend to form stones, you should try to drink enough liquids throughout the day to produce at least two quarts of urine in every 24-hour period. People who form calcium stones used to be told to avoid dairy products and other foods with high calcium content. However, recent studies have shown that foods high in calcium, including dairy foods, help prevent calcium stones. Taking calcium in pill form, however, may increase the risk of developing stones. Women taking vitamin D and calcium pills in the post-menopausal period to prevent osteoporosis, especially with a family history of kidney stones, need to be careful. If you are at risk for developing stones, your doctor may perform certain blood and urine tests to determine which factors can best be altered to reduce the risk. Some people will need medicines to prevent stones from forming.

My stone has not passed, do I need surgery?

In general, you are facing surgery if your stones are large enough to obstruct urine flow, if they are potentially harmful to your kidneys or if they are causing symptoms for which medication does not help.

Will my children get kidney stones because I have them?

Any person with a family history of kidney stones may be at higher risk for calculi. Stone disease in a first degree relative, such as a parent or sibling, can dramatically increase the probability for you. In addition, more than 70 percent of people with certain rare hereditary disorders are prone to the problem. Those conditions include cystinuria, an excess of the amino acid, cystine that does not dissolve in urine and instead forms stones of cystine; and primary hyperoxaluria, an excess production of the compound oxalate, which also does not dissolve in urine, forming stones of oxalate and calcium.

Are gallstones and kidney stones related?

No. There is no known link between gallstones and kidney stones. They are formed in different areas of the body. Also, if you have a gallstone, you are not necessarily more likely to develop kidney stones.

What is a staghorn stone?

Resembling the horns of a stag, these stones get their name from the shape they form by filling the pelvis or drainage system of the kidney (at the top of the ureter). Staghorn stones are linked to urinary tract infections. Despite the fact that they can grow large, they are often overlooked by patients because they cause minimal or even no pain. But a staghorn stone can lead to deterioration of kidney function, even without blocking the passage.
Treating this condition can be challenging. In the past, urologists relied on conventional surgery to remove the offending stone. But today they employ a combination of shock wave lithotripsy and percutaneous surgical procedures, even though patients may still need a traditional operation. In any case, it is essential that once the stone is removed, you work diligently to prevent further ones from forming. Luckily, new drugs and the growing field of lithotripsy have greatly improved the treatment of all kidney calculi, including staghorn stones.