Blood in urine is common – and stressful for patients, who want an immediate diagnosis. In this illustrated talk, urologist Alan W. Shindel, MD, MAS, guides primary care providers on sorting through the possible causes , which range from infections and traumatic injuries to kidney stones and cancer. He offers clinical pearls on assessing patients on anti-coagulants, the limits of dipstick results, and selecting the right imaging techniques. And he reviews the latest next-step guidelines, which take individual risk factors into account. After going deep on kidney stones and cancer, he lays out what clinicians need to know about scrotal conditions, including which should be considered an emergency.
Uh, as we alluded to, my niche focus within the department of urology is andrology, that is to say, men's reproductive and sexual health. Despite that particular interest and specialization I have, I do a lot of the general urology in our department as well. So certainly these topics of hematuria and peniscrotal emergencies are kind of our bread and butter and things that are very important to understand from the primary care perspective because you guys all see it quite often too. So some important things to keep in mind, this is meant to be interactive, so I will be going through the slides, but I'm hoping I can give enough time at the end to answer any questions that might arise. There's also been some recent updates, and I'm going to be updating this presentation in the near term, and I'll tell you where the major differences lie between the current guidance that came out last month at the AUA meeting and what the slides here say, but I'll try to articulate that for you during the presentation itself. So, uh, who am I? Uh, this is my basic credentials. Uh, these are some things about me and things that I do within the university. Uh, in addition to what's listed here, I'm also an inquiry advisor for the medical students, so I have a lot of involvement in undergraduate medical education. And this talk is itself based on slides that I typically present to our second year medical student class. Now I will probably dial up the knowledge base a little bit given the audience that I'm speaking to at this time, but the foundational elements that are important for medical students now are equally applicable, I think, just for the basics of what primary care and other, you know, practitioners should know about urology and hematuria specifically from the urology perspective. These are my disclosures. Uh, none of them are germane to the topic matter at hand here. Roon is a video conferencing service and ConroE is basically inpatient or I'm sorry, a consultation sent in from primary care practices throughout California with simple urology questions. I have received financial remuneration from the following entities over the last year and again for this particular talk I'm not using slides from other people. These are actually all ones that I use, but that's the standard disclosure from another slide, so that was useful. So my goal here is to discuss hematuria and kind of when I talk about hematuria, I will say it's one of the more common neurologic entities that we are called upon to evaluate. As urologists we're sort of responsible, as you all know, for everything distal to the collecting ducts. So the entities that can lead to hematuria and cause problems are things that I will be addressing with you all today, and we'll use hematuria kind of as the framework through which to discuss a number of different important neurologic pathologies. Because it's typically a little bit of time at the end, I'll also discuss some issues of acute scrotum. There's some penile emergencies we could also potentially address, but really acute scrotum and the evaluation of scrotal pain and pathology is something that again it's important to have some familiarity with, and I hope that after the end of this you'll have some grasp about how we as urologists approach these kind of problems. So hematuria, obviously as the name implies, is exactly what it says. It is the presence of blood in the urine. And the definition that we use in neurology, and it's distinct in some cases and not always widely known, is that there has to be confirmation of the presence of blood with microscopy and detection of at least 3 red blood cells per high power field on microscopy. The obvious dramatic presentation of gross hematuria means that we do manage it differently. We'll sometimes admit people to the hospital, put them on aggressive hydration, sometimes even take them to the operating room if they're having hematuria with clot retention or really refractory hematuria. But fundamentally we have the same set of diagnostic steps that we want to make sure we complete and when hematuria is present, we always want to evaluate it. Now some people get concerned as oh is it because of my aspirin? Is it because of my Eliquis? Is it because I'm on Coumadin? These are certainly things that will exacerbate hematuria, but ultimately, the presence of blood in the urine is something that is obviously abnormal, even if one is on anticoagulants, and it's therefore important for us to evaluate it. I really want to emphasize too, and this will probably come up more than once, the dipstick tests that are used so commonly in primary care offices are exceptionally good. They are incredibly sensitive and very good at detecting blood in the urine. However, they are not proof positive that blood is actually present. There's a lot of false negatives or false positives that can crop up with those. So it is very important that before someone is, excuse me, referred to urology or subjected to neurologic evaluation, we do want to get confirmation. Using a microscopy evaluation to make sure that blood is actually present before we proceed with anything else. So the differential diagnosis for hematuria is quite broad. You can start off, you know, thinking at the very top, going from the kidneys on down, all the different pathologies that affect the kidney, including many that are nephrological in nature and others which are more distinctly neurological and more our domain. You can categorize it more or less as these different categories though, so malignancy first and foremost in most people's mind. Of the ones listed here, the one that we most commonly associate with hematuria, especially painless hematuria, will be bladder or less commonly ureteral cancer. Prostate cancer, despite its ubiquity, is very seldom a cause of hematuria, but you can also see it in the context of renal cells, so particularly transitional cell carcinoma of the bladder and renal cell are what we think about in terms of malignancies associated with hematuria. Medical renal disease and I kind of put that all in one category here because as a urologist those are kind of outside of my domain of expertise and what I manage, but obviously we know there's a very broad differential for nephridides, nephropathies, different things that lead to medical renal bleeding that are again not within the scope of urology so I won't spend a whole lot of time talking about them. Nephrolithiasis, again, pretty dramatic in its presentation in most cases, an incredibly painful syndrome, usually unilateral flank pain radiating from the flank down into the groin area, very common, very important source of hematuria, and oftentimes the symptomatic presentation kind of gives away. Cystitis and pyelonephritis again common source and again in terms of just sheer numbers of diagnoses that lead to hematuria, I would say UTI, a very, very common cause of hematuria. Trauma, an important cause again, gunshot wounds, car accidents, sporting injuries, etc. It's important to note that the degree of hematuria is not always commensurate with the degree of renal injury. One can have a complete avulsion of a kidney, a complete disruption of the ureter, and even the vasculature of the kidney and have only microscopic hematuria simply because the blood is pooling in the retroperitoneum rather than going down the tube. So certainly trauma, very important cause, and then lastly, The sort of uh diagnosis of exclusion that we make in people with prostates is that we do know that as men or other people with prostates get older, the prostate gets larger, and that can sometimes be a source of intermittent bleeding, either microscopic or gross, and when we don't know what else to call it, we will sometimes say, oh, it's probably related to BPH, in which case we discuss how to manage that in a sort of a separate talk in and of itself. So infection, as I mentioned, is the most important cause, and we're probably all familiar with the presentations of cystitis, so frequency, urgency, dysuria, melodorous urine, sometimes gross blood you can see. It is distinct from pyelonephritis, a more dramatic septic type presentation typically involving fever and severe flank pain. We will see this and evaluate for it, as you all know how to do with urine culture and sensitivities and the guidance that we have currently. That in simple UTI, a person with female genitalia, non-recurrent UTI, a one-off type of situation, you can get away with just a 3 day course of some culture appropriate type of antibiotic. For the complex cases again this would be patients with a prostate, patients with recurring issues, patients with complex genital urinary anatomy, or other things that might predispose them to having worse types of infection, we do typically recommend 7 day courses for those and even longer cases, courses of antibiotics in the setting of pyelonephritis potentially 2 weeks or so depending on clinical sentiments and and whatever ID has to say if they are involved. So a question I ask rhetorically, since this is not an interactive session so much, I'll just go ahead and answer it, is that there are a number of modalities by which we evaluate the upper urinary tract. Kind of the gold standard Cadillac choice of Cadillac test of choice is a CT urogram. This consists of three separate phases the non-contrast phase, the nephrographic phase, which occurs approximately 1 minute after contrast administration. And then a delayed phase 10 minutes after contrast evaluation and really this kind of test gives you all the information you could possibly want from the neurologic perspective. The non-contrast phase, obviously very useful for a baseline and also for detection of kidney stones, about 99% of which will show up on a CAT scan, whereas some uric acid containing stones will not show up on plane films, they will show up on CAT scans. The renal phase or nephrographic phase is very important because about 90% of renal cell carcinomas arise in the renal cortex from the glomerular elements. So this phase of the CT scan is really designed to detect renal mass and determine if a renal cell carcinoma or other concerning lesion of the kidney is present. And then the delayed phase permits plenty of time for the contrast to be filtered by the kidney and excreted into the ureter, so the delayed phase gives you basically a virtual intravenous pyelogram or ureterogram. To detect any sort of filling defects of the ureters. So with this single test, it is 33 trips through the scanner. It is a dose of contrast, so it's not without its risks and downsides, but it is really the test of choice that gives us pretty much everything we could possibly want to know about the upper urinary tract. Now if this is not an option, we will sometimes turn to alternatives, and that includes MRI. If there's concerns about renal function or there's a concern with iodinated contrast, you might consider this. Keeping in mind that MRI is not quite as reliable at detecting kidney stone because of the fluid content, the water content, is much less than stone, so you're not always going to show up very well. An ultrasound is an appealing option and depending on the severity of risk of hematuria and how we classify that risk, sometimes an ultrasound is sufficient if we're not particularly worried about high risk disease like ureteral tumors, ureteral transitional cell carcinomas, an ultrasound provides pretty good information. Not quite as sensitive for stones, but pretty good for everything else and really can save patients a dose of contrast and radiation. So it is our test for what we call low or intermediate risk hematuria. In some cases where we really can't give contrast, but it's important for us to look at the ureters, we can also do at the time of cystoscopy a retrograde pyelogram where basically we inject dye retrograde through the ureterral orifice into the ureter and get a fluoroscopic image of the ureter to see if there's any filling defects of any sort. So the guidelines on hematuria, this is a little bit out of date, and I will say is that the basic paradigm still applies here. And so obviously I don't ask you to memorize this document, but I will say that the current guidance we have on hematuria is that for a person under the age of 40 with microscopic hematuria, 3 to 10 red blood cells per high powered field, no other particular risk factors or symptoms, we would consider that low risk, and in many cases a low risk patient is fine to not proceed, not to proceed immediately to evaluation. But to repeat the urinalysis in 3 to 6 months to see if the hematuria is still present. If it is, then it does make sense to potentially upgrade them to an intermediate risk category. The intermediate risk category is those patients again who have had a prior low risk evaluation but show persistent hematuria. It is also the province of people who have a moderate tobacco history, say 10 to 30 pack years, 11 to 25 red blood cells, so a bit more presence of hematuria, more blood cells are present. And other risk factors such as, you know, some sort of aniline dye exposure, maybe cyclophosphemide history, something else that again makes you concerned, and some genetic syndromes which are not the most common source for transitional cell carcinomas, but certainly anything like that that makes you a little more concerned might prompt you to say let's treat this person as intermediate risk and for those intermediate risk patients we typically like to recommend a renal bladder ultrasound, and we do recommend cystoscopy for those patients as well. Now an important distinction here and something that is again different in this 2020 guideline versus what just came out last month is that you can see that uh uh genetic or AFA individuals, women are, are assigned a high risk status if they are greater than 60 years of age. And what's different about the most recent guidance that came out again just last month is that no person of female gender or with female anatomy or born female at birth. is assigned a high risk category based strictly on age alone, whereas for people born with male genitalia AMAB individuals, if they are over the age of 60, they are by definition high risk and therefore get a different sort of evaluation. We would also apply a high risk to a person of any gender who has a greater than 30 pack year tobacco history, greater than 25 year blood cells per high power field, gross hematuria, meaning blood they can actually see. These are all things that will make someone a high risk patient, and in the high risk patient we typically do recommend a CT urogram and cystoscopy, so the more definitive, more diagnostic test, even though it does carry some contrast and radiation risks, we do say that high risk patients do probably merit the more intensive and more detailed evaluation that that entails. So in general, these are kind of the principles you could talk about. I've kind of already articulated them to some extent and again the caveat and the difference with the most recent update to the guidelines is actually only older patients AMAB assigned male at birth or male identified with male genitalia are considered high risk in the current iteration of the guidelines. And again, a person who has female genitalia, assigned female at birth who is over the age of 60 but also has tobacco risk factors would still be considered high risk as well. So one thing we can find when we do CAT scans is renal mass, and this can be divided into three or two big categories, the malignant types versus benign, and the kidney is not a very common site for metastasis. So most of the things you're going to see in the kidney that are malignant in nature are renal cell carcinomas. You can sometimes see a transitional cell carcinoma that starts in the renal pelvis, then grows into the renal parenchyma, and those are the things that you're most commonly going to see that are potentially malignant. What we see a lot more of are simple cysts, those are things that are just fluid filled sacs that are, I wouldn't say ubiquitous but incredibly common and often as a source of some concern even though they are by nature most often benign, assuming they are simple. There are a couple of solid masses that are also kind of in that borderline zone, and the important distinguishing feature here is that certain tumors that have the features of an onchocytoma, which can be hard to kind of sort out, these are not really malignant by nature, and the angiomyo lipoma, which is actually a containing tumor and that's kind of pathonemonic that if a fat containing tumor is identified inside the renal parenchyma, it is virtually always an angiomyoal lipoma and it does potentially have a propensity to bleed if it gets greater than 5 centimeters in size, but it is not a malignancy and does not require partial or radical nephrectomy for management or even ablation, frankly. So renal cysts look like this and you can see a very nice demonstration here, some labeling right for us, but a cyst, and this is your classic Bosniak one, very simple benign appearing cyst, so it's nice and smooth and round. There's no septations, no calcifications. There's no evidence solid components. There's no enhancement. It's really about as simple as they come, and this is something that we would see and say it's a cyst, we wouldn't make much deal of that. Now if this cyst had characteristics such as multiple septations, a solid appearing component enhancement. We would potentially treat it differently because there are cystic renal cell carcinomas, but this particular example we see right here, certainly very reassuring is a benign appearing cyst. You can distinguish that from a renal abscess, but again, here we have a left kidney, right kidney, and you can see once again a fluid filled mass, and this time you can see a little bit of ring enhancement, so again classic for an abscess, and also some of the perinephric stranding. You can see this kind of stranding appearance contrasting the left versus the right side and again very clearly diagnostic of a renal abscess as opposed to a cyst and this is kind of a classic picture for that. And then RIM enhancement right here again the feature to call out. So angiomyolipoma, I already mentioned that this is a tumor that is benign by nature, does not metastasize, does not cause issues with metastasis or death, and you can identify it both on macroscopic and on biopsy if fat is present, we almost virtually say that this is, yeah, this is a benign lesion by definition. It does not require surgical management. And again, the best way to kind of tell that just by looking at adipose tissue presence. Seeing what adjacent adipose tissue looks like and identifying it in the specimen, kind of gives you the diagnosis of a benign renal lesion. Pyelonephritis, once again you can see the patchy heterogeneous nature of this left kidney, so very classic, also very classic inflammation adjacent to it. So once again a very nice classic picture, and you would see this patient having probably symptoms of pretty severe flank pain, very likely uh signs of sepsis and fever as well. So once again a confirmation of my CAT scan here that this is a pyelonephritis type picture picture. And renal cell carcinoma once again can look like this, and you can see how ultrasound is often unable to detect a lesion, although it's not very specific or precise. So obviously you can see you get a lot more out of this when you get your CAT scan done, and you can see this kind of classic for a very large renal cell carcinoma, this situation of peripheral enhancement, but central necrosis. This is a rather large renal cell carcinoma involving the lower pole of the right kidney. So renal cell carcinoma is interesting. I remember when I was a 3rd year medical student on my medicine clerkship over at the VA, how I did a presentation on it, I guess I was predestined for urology, and what I came across was the notion that renal cell carcinoma is known as the internist tumor, and the reason it's known as this is because it has a wide variety of paraneoplastic syndromes, including elevated shooting of LFTs, even in the absence of metastasis. Polycythemia, hypercalciuria, and calcemia, a lot of different things can happen and historically before a cross sectional imaging was so ubiquitous, a lot of the time renal cell carcinoma was detected, uh, sometimes by presence of flank mass and hematuria, but sometimes it's because of the presence of unusual and unexplainable perineoplastic syndromes. So some demographic data about renal cell carcinoma right here. And again, the classic triad was this nowadays because everyone's getting CAT scans all the time, we find a lot of these things sort of incidentally when people are getting evaluations done for some other reason and you can see once again some of the lists of things that are commonly associated as perineoplastic syndromes in the context of renal cell carcinoma. So the evaluation for this, uh, cross sectional imaging, again, that's typically how they're all detected these days. So you already have your CAT scan usually when the diagnosis is made. There used to be a dogma that you should not biopsy these for concerns of causing seeding, although that's sort of gone by the wayside, and currently biopsy is something that we certainly deem useful in some cases if there's uncertainty about the benefit of treatment or if there's concern about metastatic disease. A needle biopsy is certainly appropriate to do, although not always that necessary and frankly not always that accurate because sometimes one can do a biopsy and wind up with a specimen that is not really reflective of of the rest of the tumor. We do typically recommend CBC and CMP have not already done because of the aforementioned perineoplastic syndromes, and a chest X-ray, because this is one of the primary metastatic sites for renal cell carcinoma is into the chest. So this is a tumor that is managed almost exclusively, at least primarily with surgery, and again, radical nephrectomy was the standard of care for many, many years, and laparoscopic techniques are very strongly preferred these days because it is possible now to do laparoscopic renal surgery by most practicing neurologists, in fact. A partial nephrectomy is always preferred, and certainly if the tumor is less than 4 centimeters, which is sort of the threshold for metastasis, so if it's less than 4 centimeters, it's very unlikely that's caused any immediate problem and it's probably best managed at less than 4 centimeters with a partial nephity to preserve as many nephrons as possible. For a person who is very old or conversely very young and looking at the potential for losing a lot of kidney function with the surgery, we also do have percutaneous ablation options using either cryo or radio frequency, which is gaining traction over the last couple of decades as a way to manage these things in a minimally invasive fashion. So here we have a specimen again. You would never see this in the modern era. I would hope a very small renal tumor at the surface there on a kidney that's been bivalved and basically this would be a partial nephrectomy in the modern era. On the other side of the screen with a white arrow, you can actually see once again a bivalved kidney and actually what you're seeing here is an invasion of the renal vein by these tumors, and these can actually progress as a prior slide had indicated. Renal cell carcinoma can grow up the IVC and even into the right atrium, and obviously when that happens we do get our colleagues from hepatobiliary or even cardiothoracic surgery involved to help us take these things out, so they can be a quite dramatic presentation and a dramatic surgery necessary for the more extreme versions of renal cell carcinoma. So, Oh, here we go, labeling what we already said. So again, a rhetorical question in this audience, but I will typically ask medical students to tell me what kind of stones exist, and I will say, I'll just give them to you right here, the most common type we see are calcium oxalate, and these come in two different flavors monohydrate and dihydrate. The only really important distinction there is that the monohydrate stones are the second hardest kind of stones that exist in the universe, and they can be very difficult to fragment, and you don't really know that until you actually go in there and get it out and analyze it. But these are the most common kind of stones, the kind of the garden variety stones we see quite often. We also see a fair number of calcium phosphate stones, and this can occur in some cases because this precipitates out more readily in alkaline urine. And one of the kind of standard of care options that we've used to treat many different kinds of kidney stones, especially uric acid. But potentially other types as well is potassium citrate, which is an alkalizing agent. Citrate itself is also a stone inhibitor, but one thing that can happen if one overcorrects is that you can wind up with very alkaline urine in which calcium phosphate will start to precipitate out. So we have to be conscious with how we use this. This is a secondary kind of stone that can form if we overdo it. Uric acid stones are very important cause, and sometimes they're an importantitis for other stones to occur. As you might guess, these are most common in patients with a gouty diathesis. You can also see it in tumor lysis syndrome and in Lenain syndrome, if you ever encountered that, these are the kind of stones that people with that syndrome will develop. As I mentioned earlier, they tend to be radiolucent on plane film, but they do show up on CAT scan, and unlike many other kidney stones that exist. These stones are actually dissolvable, so as I said earlier, you could potentially treat these non-surgically using alkalizing agents, and it's not quick and not sudden. If someone is in acute distress, you don't want to wait for dissolution to occur, but long term for prevention or for non-obstructing stones, this can be an appealing option to manage these things without the need for surgical intervention. Struvite, also known as magnesium ammonium phosphate, they are named the famous Baron von Stru, who I don't think I'd want that a stone like this named after me, but that's what happened to poor Do poor Baron von Struve. These are the kind of stones you see in people who have chronic UTIs related to the presence of urease splitting bacteria, classically Proteus, but some other variants as well. These are stones that people, particularly those with spina bifida, spinal cord injury patients, those who are again predisposed to urinary tract infections, will oftentimes develop these due to the chronic infection, and these tend to be very large, very bulky stones, typically not very hard, but based on sheer volume and size, they typically require a different approach in terms of how we access them to treat them. Cystine stones, despite being quite rare at about 1 or 2%, are renowned as the hardest kind of stones that exist, and they are one of the few that is clearly genetically related, having to do with a defect of amino acid transporter for cysteine leading to the buildup of these very, very hard, very rock solid stones that oftentimes present early in life and have a very strong familial component. So there's 3 major points at which a stone can become hung up on its way out of the human body. The these choke points more or less correspond with the different locations for pain. So the first of them is the urethral pelvic junction, right where the ureter and the renal pelvis join together. When people have a stone impacted at this level, they will typically describe pain in their flank, kind of pain in the flank, and usually incredibly intense, coming in waves, debilitating sort of pain. It always comes up the question of, well, which is worth kidney stone or or childbirth because that's always a metric and a thing we use to compare. Women who've had both oftentimes will say the kidney stone is much worse, and some of that has to do with the fact that nobody wants a kidney stone, even though some people want a baby. But I think more than that, it is a very debilitating, excruciating pain associated also with nausea, which makes it all the much worse. So it is a really, really bad kind of pain. As the stone moves down, the second major choke point at the crossing of the iliacs, and as you can see from the text, at this point when people have a stone at this location, they will oftentime endorse that the pain in their flank is now radiating around to their front, so kind of down around the back, potentially going into the groin area. At the very last choke point at the utero vesicle junction, there can be some specific urinary dysuria frequency type symptoms. And oftentime pain that extends all the way down into the labia or the scrotum, depending on the genitalia of the person who you're talking about. They can have pain that radiates that far down because of referred sensation. And once it's into the bladder, once the stone is passed out of the ureter itself, most people experience a very sudden and complete resolution of pain. So that's really the painful part is getting it down the ureter, not out of the bladder once it's there. With some major risk factors for kidney stones, again, dehydration, excuse me, being the most important one. So, even though it's listed at the bottom here, it's one that I always tell people to think about because it is one that we have some element of control over. As I mentioned, gout and gouty diathesis, hyperparathyroidism, the classic mnemonic of stones, bones, and abdominal groans, I think I got that right, but those are things that are commonly associated with calcium containing stones. Chronic diarrheal states for a couple of different reasons, leading to absorption of oxalate from dietary food. And low calcium intake as well as dehydration and then low urinary citrate. These are all very important causes for kidney stones. So in terms of once you're past the acute episode, the stone is either passed, and again if a stone is 44 millimeters or less, it will typically pass. Um, but if the stone has passed, the person's now saying what do I do next. We typically have a pretty limited workup we do. So if it's from one of these things, do a basic BMP, calcium uric acid, and urinalysis, that's probably good enough to kind of figure out, OK, is there something else clearly metabolically wrong, and if there is, if one of these things is identified as abnormal, then there may be further evaluation, but that's kind of where we stop most commonly for the low risk patients. For these patients who are recurrent or child children who have renal insufficiency or they have risk factors on the other side listed there, we will typically recommend getting a urine supersaturation profile, which is a 24 hour collection of urine into a big jug. We send it off to have it analyzed. We look for anything that's metabolically abnormal and depending on what we find. There may be medical options or behavioral options that we will recommend to people, including things such as thiazides, allopurinol, if there's uric acid problems, alkalinization often have a correct answer as well, but the precise intervention indicated in part by what we find. So as I mentioned, a lot of stones that are less than 4 millimeters are probably going to pass. Once they get beyond that point, it becomes more of a dice roll, and certainly a stone greater than 1 centimeter, probably not going to go anywhere, at least not anywhere you want it to go, and we'll probably need some sort of intervention. We can do the alkalelization thing if you have time and the patient's not in acute distress. We typically prefer potassium citrate because sodium bicarb is pretty hard to tolerate, but potassium citrate generally people do pretty decent with. You can do temporizing things if a person is septic from an obstructing stone that is one of the few genuine neurologic emergencies. So if we want someone to be quickly decompressed, we can put a stent in or a nephrostomy tube potentially to bypass the stone and allow the infection to clear and also relieves pain in most cases. Extracorboreal shock wave lithotripsy is less commonly utilized more often because it has better clearance rates. We prefer to do ureteroscopy in the modern era. So basically using our long fiber optic camera here. I'm going up inside of the ureter and I will say it's one of my favorite surgeries of urology because basically you're taking your laser and you're blowing up this big asteroid and you're making someone feel very much better than they were. So it's really an incredibly satisfying surgery. It's a technically fun surgery once you get set up. So it's really one of the fun things about being a urologist and getting to do this kind of operation for people. For those large and bulky stones, uh, particularly struvite, uh, or any stone that greater than 2 centimeters in diameter, we will perform a percutaneous nephrolithotomy, which is basically inserting a nephroscope directly into the kidney through the back. And with this device we're able to apply a dentist drill or a device very much like one to grind the stone up, but it's a very efficient way to deal with large volumes of stone faster than you could ever hope to accomplish with simple ureteroscopy in our small, you know, 1000 micron labor or, you know, 250 micron laser. So that's the procedure we take for larger kind of stones and certainly if someone is sick, as I said earlier, you just put a scent in or a nephrostomy and let them cool off before definitive management. So in terms of evaluating the lower tract, so we've talked a little bit about things you find in the upper tract that is kidney stones and renal masses. If you want to evaluate the lower tract, we do cystoscopy, and a cytology test is sometimes used as an adjunct. There is a test that has recently gained some level of prominence called CX bladder that is also being utilized more commonly and did make it into the guidelines now. As an alternative to cystoscopy, not a preferred one, so certainly we still believe cystoscopy is the standard of care, but we are seeing growing traction that urine-based test for biomarkers and that one in particular may be to some extent taking the role of cystoscopy in certain low risk cases and maybe more down the road. So I think it's an exciting development. We'll see how it all pans out, but it is something that is changing from the last iteration of the guidelines. A bladder cancer is what we're looking for, and again we'll find other things and we'll talk about those things, but really bladder cancer is the most concerning possibility and I will say that it is a very distinctive looking tumor. You know, some of the high grade tumors are carcinoma in situ, which is actually quite serious for us because it has a high rate of progression, but the classic appearance of a low grade bladder cancer is exactly what you see in the upper panel there, like much like a sea anemy. It has this kind of fronial or bush-like appearance. And truthfully it's cancer, so it's never a good thing to find, but it is generally a low grade cancer when it has this sort of appearance. And in that case you oftentimes can treat the patient simply with resection without the need for a whole lot of other fancy treatments. The higher grade, more aggressive tumors obviously sometimes do require quite a bit more work, and we'll talk about that in a few more slides. Bladder cancer, quite common. Again, most common in men who are male identified, you know, male gender, male sex, and a lot of that had to do with tobacco exposure, industrial exposures, etc. I think that the ratios are changing here where I think there's less and more of a flattening out of the difference between genders, but I think it is still something that is most commonly observed in people who are male and most importantly observed in people who are tobacco users. It has a pretty high incidence rate, a pretty high survival rate, because many of these tumors are in fact low grade, but it can be a very expensive tumor because it requires a lot of surveillance, and when people do need complicated surgeries done, it can be very big surgeries with a lot of postoperative care in terms of how do you manage urine when the bladder is no longer there. So the way it is treated, typically we'd get diagnostic and sometimes even therapeutic results with a transurethral resection of the bladder, basically looking in with our device which looks very much like a cutting loop that's electrified. We determine how deep it invades. You can see the TNM classification system right here. So anything that is T1 or lower is something that can be managed with simple resection, and in some cases we'll do a repeat resection and we will certainly do surveillance in the setting of T1 disease or less. When, however, we get to the level of muscularropria invasion, T2, T2, T2, T3, T4, we're into the realm where you really can't reliably resect it in its entirety and you have to start thinking about something more invasive, such as removing the bladder, doing a cys cystectomy. Uh, we do sometimes utilize, especially for high risk patients, uh, some sort of intravesical chemotherapy to help reduce the risk of recurrence, and we also use uh BCG, uh, bacillus calumetdien, which I probably didn't say it right in French, but basically it is a attenuated mycobacterial species that induces an immune response, we think. And has been shown when applied to patients with high grade disease or carcinoma in situ to reduce the risk of recurrence. So it is a useful treatment that can sometimes be its own set of problems in terms of side effects and bother, but it is a treatment we will apply for those cases of a high grade non-muscle invasive disease and not other ones so. And for teacher disease again, typically radical cystectomy in some cases involving a neoadjuvant chemotherapy to shrink the thing. There are bladder sparing protocols used most commonly in Europe and sometimes in this country. They're never quite as good, and a lot of people who go down that route wind up regretting it because it becomes so difficult to manage the post chemo or post-radiation bladder. They wind up sometimes with very terrible urinary tract symptoms that may be worse than in fact having a cystectomy in the first place, but it is an option for people who will not part with their bladders. So those are the basic things to think about when we're discussing hematuria, and obviously there's a lot more that I could discuss along those lines. I'm happy to come back to it later if people have additional thoughts or considerations, but I would like to spend a little bit more time that we have talking about other common emergencies that we should all have some familiarity with and how to recognize. And again, here we're talking about primarily acute scrotum and scrotal masses. So the differential diagnosis of scrotal entities, benign ones, so hydrocele, spermatocele, varicocele, these are all entities that do not require management. Certainly in the case of hydrocele or spermatocele, if it is very large and bulky and getting in the way, surgical management can be contemplated. You can say the same for varicocial, which is truthfully quite commonly diagnosed in ultrasound, but really there aren't many really good reliable ultrasound-based criterion for what constitutes a clinically relevant varicocial. So I see it called all the time, but I see plenty of patients who really don't have any bother and don't have any fertility concerns related to it. So I don't generally make much of that unless they have a clinically palpable varicocial. And they're having concomitant issues with either conception or with pain, and the classic kind of varicocial type pain is an achy, heavy, weighty sensation localized most commonly to the left hemiscrotum, worse with exercise, worse at the end of the day, it gets better when you lay down. That's very classic. And a person who presents with that in an exam consistent with varicose is the person who I say this person may in fact benefit from treatment of a varicose, whereas in many other cases it's really not much value at all. Infection also quite common, so epidemal orchitis, kind of two sides of the same coin and typically concomitant, so this is typically a pretty painful condition associated with sexually transmitted infections and also coliform bacteria in the context of people who engage in anal insertive intercourse or people at the extremes of age, so neonates and men over the age of 60 are more prone to orchitis and epididymitis, but it can occur obviously at any age. There are a number of emerging conditions. So spermatic chord torsion, oftentimes called testicular torsion, but really it's spermatic cord, which is actually torsing. So spermatic chord torsion, a very important entity, trauma again, usually fairly self-explanatory, and then Fose gangrene, necrotizing fasciitis of the scrotum and perineal area, which is again a surgical emergency with a very high mortality rate. Lastly, testicular cancer, again a very common entity in Northern European populations but can occur in any group. It's something that we certainly think about and talk about, uh, but very seldom does it actually present with pain. So, uh, briefly, hydrocele here, very common in neonates, it's basically just layers of fluid between the tuica vaginalis, so the onion skin layers of tissue that the testicle takes with it as it migrates down from the near the kidney down into the scrotum in utero basically is a potential space where fluid can accumulate, and they can occur for many reasons. They occur sometimes in the context of prior inguinal surgery like a hernia repair or a varicoseal repair you can find a hydroceal developing. We typically leave these alone if they are very large or if they're getting in the way, you can do an outpatient surgical procedure that is oftentimes pretty effective. It's a pretty straightforward kind of surgery for the people who are really troubled by these things if they're having trouble. Epidemial architis, uh, again, infection of the testicle or epididymis, and again typically presents a little bit differently with progressive pain, oftentimes also in the context of urinary tract symptoms and discharge, and it is noteworthy that it's usually unilateral. The pain is localized above and you can actually alleviate the pain with elevation. So basically lifting up the scrotum and making it a less dependent position will reduce scrotal pain related to epid orchitis. Not for other entities, so certainly if a present sign is positive, it suggests infection. If it's negative, it implies that it's something else. You do most commonly see gonorrhea chlamydia being the etiology of epidemi orchitis in sexually active persons, but coliform bacteria, as I mentioned earlier, can be seen in people with scrotums and testicles at the extremes of age and also those who engage in anal insertive sex. And for this we simply treat it with at least a 2 week course of appropriate antibiotics. My experience has been that many men after epidemi orchitis have pain that lingers long past when the infection is present, and I'm not sure exactly why that is, but you have to understand and talk to patients that when they have this diagnosis, they're probably going to have pain for a while, even when the thing is treated appropriately and effectively, they're probably going to have some aching that persists for probably several months minimum, and they just have to understand that and recognize that that's pretty normal. Dermatochord torsion, again we call it testicular torsion, it is most common in pubescent boys, and the reason for that we think is that this bell clapper deformity, the anatomical defect that causes the testicle to be able to twist on its own blood supply, is not really relevant when you think about a very small prepubescent testicle. However, when the testicle starts to grow under the influence of the pituitary gland of puberty, that testicle grows to the point where it becomes heavy and less prone to be able to twist back and forth so easily. So testing or traumatic chord torsion can happen at any age, but really the peak incidence is what you see in the pubescent uh aged boys. It is exquisitely painful. The testicles are rock hard. It is typically oriented, somewhat funny. You can see abolition of the cremasteric reflex. And sometimes some other different rotations. It is important to distinguish that you can also have more commonly in elementary school aged boys this appendix torsion. So the remnant tissue that would have become a fallopian tube can itself be quite large and can twist on its blood supply and presents as a very localized scrotal pain. The testicle itself feels normal in these contexts, but there's a hard nodular thing, and I've never seen it myself, but typically, They described this blue dot sign where you see the ischemic uh kind of a cyanotic epididymis through the scrotal skin is the part that's toursing and this is managed expectantly uh with conservative man because it does not require surgery. You don't need a scrotal ultrasound to make this diagnosis, and certainly you wouldn't want to wait around for a scrotal ultrasound to take someone who you really believe is having spermatic cord torsion, but it is important and if you can get it and at UCSF we usually can pretty expeditiously. You see this difference here of blood flow on the left side, but clearly nothing on the right, and you can also see some more edema on that side, so very consistent with spermatic core torsion on that right testicle. So surgery is the mandate, and if you get the patient back usually within 12 hours or so, usually do pretty well, but time is of the essence. You really don't want to waste any time. So if there's any ever, ever any concern whatsoever, you got to get into the operating room right away. Testicular fracture occurs again usually after trauma and usually not terribly subtle. A lot of these are sporting injuries. It could also be the result of interpersonal altercations or fights where someone is struck in the scrotum. When you see the situation, you can see basically on this right side, normal testicle, the injured testicle, sorry, in your testicle over there with clear evidence of rupture, no clear delineation of the tunica albuginia. This would be something that we would want to take him to the operating room. Fairly urgently to repair debride any dead tubules and then close the tunicle over the ruptured testicle and usually we can salvage it pretty well assuming it's not completely obliterated, you can just debride dead tubules, sew the tunicle over it, and salvage most of the testicle, even in these cases of testicular injury. Testicular cancer is the most common thing, and again it's important to recognize that people oftentimes get worried that oh is my scrotal pain testicular cancer or oh is this thing I find in my testicle cancer or my scrotum cancer. Testicle malignancies of the scrotum are almost exclusively, I'd say probably 99% of the time intratesicular. So if it's not in the testicle, it is unlikely that it is a malignancy, although it's not impossible. Most of these are germ cell tumors derived from some matigonal stem cells. There's some rare non-germ cell tumors of the testicle, which I won't go into here, but they are most commonly germ cell tumors. We evaluate them with the scrotal ultrasound. The tumor markers of interest include AFP, HCG, and LDH. And we typically will want to get cross sectional imaging of the chest, abdomen, and pelvis because the retroperitoneum, or rather the retroperineal lymph nodes and also the chest are the most common sites of metastasis for testicular malignancies. And in the treatment, radical orchiectomy using an inggual incision, we choose this because we want to make sure we go through the pattern through which the testicle descended, and the theory here is that if you go through the scrotum, you're potentially disrupting the normal lymphatic flow. So testicular cancers have a very stereotyped, very predictable pattern of metastasis. So if you want to make sure that we stick with the standard templates for management that we use, we make sure that we do not violate the scrotum, so we make the incision, as you can see up high here in the Iguana canal, much like we do for a hernia repair, same basic incisional approach. So, uh, fast facts testicular cancer, most common in people of Northern European descent, however, it can occur in any group. It is amongst the most curable of all solv malignancies that exist. So really a lot of what we do these days is not so much surviving testicular cancer, but survivorship. And so issues of fertility, issues of testosterone production, issues of body image, etc. are really preeminent in these patients now. Assuming again that they're getting a proper treatment, they are very unlikely to die from this sort of malignancy in the modern era. Some of the risk factors that go along with it cryptorchidism, Klein filters, any prior testicular tumor or family history obviously somewhat concerning. It remains a pretty rare tumor though, even in those high risk populations. We don't see this very often, but it is something very important to detect because it is occurring largely in young men, and if you don't catch it early, it becomes much harder to treat. Cornea's gangrene, once you've seen it, you can probably usually pick it up most times. So it's your classic situation. Oftentimes patients with diabetes, uh, presenting with fever, severe leukotoidosis, scrotal crepitus, altered mental status, etc. This has a very high mortality rate even with urgent management, but certainly the sooner you get into the operating room, the sooner you debris the dead tissue, the greater the chances of survival. And we see here again a relatively early onset of Fournier here, but you can see, you know, a rapidly spreading, necrotizing infection of the scrotum in this case that needs to go to the operating room right away. So with that we have about 15 minutes left over. I appreciate everyone's attention. Uh, typically this is part of a two part lecture, so the urology break, certainly you're welcome to take it now if you so choose, but I'm also happy to have everyone stick around and do any QA. So thank you all for your attention.
