Emergencies in Urology - part 3 pptx

ly established. Either drainage technique can be highly effective with minimal risk of treatment-related complications. Since no clear consensus regarding optimal treatment can be gleaned from published series, the choice of drainage should be selected on the basis of in- dividualized patient characteristics, the planned dura- tion of stenting, available institutional resources, and the surgeon’s preference. 10.4.2 Immediate Definitive Interventions If no indications exist for temporary drainage procedures, immediate definitive therapy can be considered. Use of immediate definitive therapy is more common when the cause of flank pain is urinary calculi and only considered when partial upper tract obstruction is present.Inthisscenario,thesize,number,andlocationof the stones impact the choice of endourologic treatment. Immediate management of partially obstructing stones in the kidney and ureter should follow the recommendations set forth in the AUA nephrolithiasis treatment guidelines (Preminger et al. 2005; Segura et al. 1997). In reality, advances in endoscope design and instrumentation make ureteroscopic approaches to these problems much more appealing than ever before. An additional benefit of ureteroscopic treatment in the setting of acute management with partial obstruction is the ability to assess intraoperatively for unrecognized infection or contributing abnormalities such as ureteral stricture. Also, if circumstances are encountered that make ureteroscopy less optimal in the acute setting, the threshold should be low for stenting the patient and returning at a later date for definitive treatment. In the setting of life-threatening urinary tract infec- tionssuchasemphysematouspyelonephritiswithob- struction, temporary drainage procedures may provide suboptimal treatment. Nickel has noted that relief of obstruction and antibiotics are usually sufficient treatment, but that nephrectomy should be considered in non-responders (Nickel 2002). Since the contemporary mortality rate remains approximately 75% for the typical diabetic patient that develops emphysematous pyelonephritis (Nickel 2002), we favor immediate traditional treatment with nephrectomy rather than an initial trial of temporary drainage. 10.4.2.1 Immediate Shock Wave Lithotripsy In the setting of partially obstructing stones, shock wave lithotripsy (SWL) has also been performed as immediate treatment (Kravchick et al. 2005; Doublet et al. 1997; Tligui et al. 2003; Joshi et al. 1999). While SWL in this situation would be less invasive, one theoretical concern would be treating a stone with SWL in the setting of unrecognized infection. SWL would provide little opportunity to diagnose an unsuspected infection and thereby alter treatment plans. Nonetheless, in the absence of indications for urgent upper tract decompression, some authors have acutely utilized SWL. In a recent report, Kravchick and colleagues reported a prospective randomized trial of emergent SWL vs scheduled SWL (treatment within 30 days of diagnosis) for upper urinary tract stones associated with acute renal colic (Kravchick et al. 2005). None of the patients had presenting indications that warranted a temporary drainage procedure. Emergent SWL was associated with a higher success rate (72%) than delayed treatment (64%). In addition, scheduled (delayed) treatment was associated with significantly prolonged hos- pitalizations and recovery at home. Other groups have noted favorable experiences with emergency SWL. For instance, Doublet and associates found a significant relationship between stone location and stone-free rates after emergent SWL (Doublet et al. 1997). In their report, proximal stone treatment was associated with a 65% success rate. More controversial is the use of emergency shock wave lithotripsy (SWL) for immediate definitive management of completely obstructing stones (Joshi et al. 1999). Among 82 consecutive patients with completely obstructing stones treated by Joshi and co-workers, 26 patients underwent percutaneous nephrostomy tube placement followed by scheduled SWL, 40 patients underwent retrograde stent placement followed by scheduled SWL, and 16 patients underwent urgent in situ SWL alone without prior drainage procedures (Joshi et al. 1999). All SWL procedures were performed on a Sie- mens Lithostar Multiline or Lithostar Plus lithotripter. The mean stone size was 8.98 mm (range, 4–25 mm) and stone size was not significantly different among treatment groups. Infectious complications related to urgent in situ SWL were not observed. Urgent in situ SWL was associated with an overall success rate of 81% compared to a 70 % success rate in the stent + SWL group and 54% success rate in the nephrostomy tube + SWL group. Success rates were highest for in situ SWL performed on proximal ureteral stones. While Joshi and colleagues report favorable results, additional clinical evaluation appears warranted before urgent SWL can be recommended for emergent treatment of completely obstructed stones. Indeed, the presence of completely obstructing stones would traditionally mandatetheuseofatemporarydrainagetechnique prior to delayed definitive treatment. 10.4.2.2 Immediate Definitive Treatment in Pregnancy Definitive management of pregnant females with obstructing stones is also controversial. Traditional treat- 114 10 Failure of Urinary Drainage: Upper Urinary ment has been temporizing with placement of a stent or percutaneous nephrostomy until the postpartum period in which definitive endourologic management is performed. With advances in intracorporeal lithotripsy and ureteroscope design, ureteroscopic stone fragmen- tation and extraction has been successfully performed in pregnancy as an alternative to temporary drainage techniques. Despite the gravid uterus, small-caliber semirigid ureteroscopes can typically be placed without difficulty (Watterson et al. 2002). In part, physiologic dilation of the ureter during pregnancy facilitates ureteroscope passage. Since ureteroscope passage is relatively straightforward in pregnancy, the need for intraoperative fluoroscopy is typically minimized, if needed at all. In fact, if imaging is needed, this can al- ternatively be accomplished with US monitoring (Wat- terson et al. 2002). Watterson and colleagues reported use of ureteroscopy and holmium:yttrium-aluminum-garnet (YAG) laser lithotripsy in eight patients with ten symptomatic ureteral stones and two encrusted stents (Watterson et al. 2002). Treatment was performed at a mean gesta- tional age of 22 weeks (range, 10–35 weeks) and the mean stone diameter was 8.1 mm (range, 4–15 mm). The mean operative time was 39 min (range, 20–70) and an overall success rate of 91% was achieved without obstetric or urologic complications. The authors concluded that modern ureteroscopic techniques in pregnantfemalesweresafeandobviatedthedisadvan- tages associated with long-term stenting or nephrostomy tube placement. Favorable results with ureteroscopy have also been suggested by Lifshitz and Lingeman. Among ten patients with ureteral calculi in pregnancy, six patients underwent first-line ureteroscopic evaluation without complication (Lifshitz and Lingeman 2002). 10.4.2.3 Postobstructive Diuresis After urgent relief of upper urinary tract blockage, patients with bilateral obstruction or obstruction of a sol- itarykidneyareatriskforpostobstructivediuresis. The chronically obstructed patient with signs and symptoms of fluid overload including pedal edema, congestive heart failure, increased abdominal girth, weight gain, and azotemia is more likely to have this problem (Gulmi et al. 2002). Postobstructive diuresis is classified as physiologic, pathologic, or iatrogenic. In the physiologic form, the diuresis is caused by retained free water, sodium, and urea. The pathologic form is associated with impairment in renal concentrating ability or sodium reabsorption. When patients are given high volumes of intravenous fluid containing dextrose, glu- cose reabsorption in the proximal tubule can be ex- ceeded, leading to the iatrogenic type of postobstructive diuresis. While postobstructive diuresis can be thought of as these three types, the reality is that many patients experience mixed patterns. In addition, the development of postobstructive diuresis after relief of upper tract obstruction is relatively rare. Furthermore, most patients that develop the problem have a physiologic-type diuresis that rapidly returns to normal. In fact, providing the patient access to free water and avoiding the use of intravenous fluids usually is enough to remedy the situation (Gulmi et al. 2002). Nonetheless, it is important to identify patients at risk for postobstructive diuresis after relief of upper tract obstruction. Following the drainage procedure, urineoutputshouldbecarefullymonitored,especially for patients with evidence of chronic obstruction and fluid overload. When urine outputs are higher than 200 ml/h for 2 consecutive hours, urine and plasma osmo- lality should be obtained to determine the type of diuresis. In the presence of low or iso-osmolar urine, the alert patient with access to water will typically normal- ize the serum creatinine and blood urea nitrogen within 1 or 2 days. Until the diuresis is corrected, urine output should be carefully monitored (every 2 h), the patient should be weighed daily, and serum electrolytes should be checked twice daily (Gulmi et al. 2002). Fur- thermore, it is important to assess the adequacy of hy- dration while the postobstructive diuresis is being treated. To achieve this goal, postural vital sign assess- ments should be utilized at a minimum of every 8 h as the patient is being treated for the postobstructive diuresis. In situations where the diuresis continues for more than 2 days and the urine persists with a low osmolari- ty, concern for a pathologic type of diuresis is increased. The alert patient continues with oral intake, but if serum electrolytes show unchanged elevations in creatinine and blood urea nitrogen, intravenous fluid (0.45% sodium chloride with 5% dextrose) should ad- ditionally be started. In most instances, urine output is replaced with the intravenous fluid as a ratio 0.5 cc of saline to 1.0 cc of urine output and this treatment is continued with frequent monitoring until the diuresis stops. This type of pathologic diuresis isrelated to a water diuresis secondary to damage in the distal tubules. In the rarest form of pathologic postobstructive diuresis, significant sodium loss also occurs secondary to distal tubule damage. Correction of this diuresis involves 1:1 replacement of urinary sodium with intravenous saline. In this form of diuresis, patients are at risk of volume depletion and vascular collapse (Gulmi et al. 2002). Faced with issues of postobstructive diuresis in a patient with fluid overload and uremia, nephrologic consultation is advised. 10.4 Acute Urologic Management 115 10.4.2.4 Summary In summary, patients without indications for temporary drainage procedures can be definitively treated at presentation. In the majority of cases, this urgent management iscomparabletomanagementofsymptomatic stone patients with partial obstructing stones who are not candidates for conservative treatment protocols. In this setting, all endourologic treatments have been used to treat stone disease. With improvements in ureteroscope design and instrumentation, however, we have increased utilization of ureteroscopy for these stones. Favorable results can be expected with ureteroscopy. In addition, direct stone manipulation pro- vides an opportunity to alter treatment in the setting of an unrecognized infection. Despite favorable early re- sultswiththeuseofureteroscopictreatmentofstones in pregnancy, we have continued to favor retrograde stenting in symptomatic patients failing conservative treatment. 10.5 Delayed Definitive Interventions Delayed definitive interventions for patients with upper urinary tract obstruction are performed for patients who have responded appropriately to temporary drainage. Most commonly this is the stone patient that for one reason or another required a temporary drainage procedure. After resolution of the underlying treatment concerns (i.e., infection, inflammation, etc.), de- finitivestonetreatmentcanbegivenwithendourologic techniques catering to the size, location, and laterality of the stones. In most instances, a minimum delay of 2–3 weeks is needed before definitive treatment is performed. For upper urinary tract obstruction unrelated to stone disease, delayed definitive interventions are also undertaken once the additional diagnostic workup has been completed to recommend optimal treatment. The complete diagnostic workup and must be tailored to the individual patient. When obstruction is unrelated to stone disease and the patient presents urgently, empha- sisistypicallyfirstmadeontemporizinginterventions. Once the patient’s obstruction has been temporarily re- lieved and once the urgent presenting signs and symptoms have been stabilized, additional diagnostic and therapeutic intervention is based predominantly on the radiographic evaluation. Not uncommonly, the diagnostic workup can be completed on an outpatient basis after the patient has been released from the acute care setting. A discussion of definitive treatment options for the variety of problems associated with upper urinary tract obstruction is beyond the scope of this chapter. 10.6 Conclusion Failure of upper urinary tract drainage is an emergent urologic condition. In many cases, a thorough history and physical examination can facilitate an accurate diagnosis. Advances in radiographic imaging have also improved the ability to differentiate both intrinsic and extrinsic causes of obstruction occurring in one or both kidneys. On the basis of the presenting signs and symptoms and with the radiographic information, a safe treatment plan can be instituted, providing neces- sary temporizing therapy or immediate definitive treatment. After the urgent problem is addressed, further diagnostic evaluation can be performed to ulti- mately treat underlying factors contributing to the initial presentation. References Ather MH, Memon W, Rees JR (2005) Clinical impact of inci- dental diagnosis of disease on non-contrast-enhanced helical CT for acute ureteral colic. Semin Ultrasound CT MRI 26:20 Chung SY, Stein RJ, Landsittel D etal (2004) 15-year experience with the management of extrinsic ureteral obstruction with indwelling ureteral stents. J Urol 172:592 Colistro R, Torreggiani WC, Lyburn ID et al (2002) Unenhan- ced helical CT in the investigation of acute flank pain. Clin Radiol 57:435 Croft BY, Joyce JM, Parekh J et al (1996) Nuclide studies. In: Gillenwater et al (eds) Adult and pediatric urology, 3rd edn. Mosby, St Louis, pp 193 Evans HJ,Wollin TA (2001) The management of urinary calculi in pregnancy. Cur Opin Urol 11:379 Diblasio CJ, Snyder ME, Kattan MW et al (2004) Ketorolac: safe and effective analgesia for the management of renal cortical tumors with partial nephrectomy. J Urol 171:1062 Doublet JD, Tchala K, Tligui M et al (1997) In situ extracorporeal shock wave lithotripsy for acute colic due to obstructing ureteral stones. Scand J Urol Nephrol 31:137 Gulmi FA, Felsen D, Vaughan ED Jr (2002) Pathophysiology of upper tract obstruction. In: Walsh PC et al (eds) Campbell’s urology, 8th edn. Saunders, Philadelphia, pp 411 Hattery RR, Williamson B Jr, Hartman GW et al (1988) Intrave- nous urographic technique. Radiology 167:593 Heidenreich A, Desgrandschamps F, Terrier F (2002) Modern approach of diagnosis and management of acute flank pain: review of all imaging modalities. Eur Urol 41:351 Joshi HB, Obadeyi OO, Rao PN (1999) A comparative analysis of nephrostomy JJ stent and urgent in situ extracorporeal shock wave lithotripsy for obstructing ureteric stones. BJU Int 84:264 Kalyanakrishnan K, Scheid DC (2005) Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician 71:933 Kawashima A, Sandler CM, Goldman SM et al (1997) CT of renal inflammatory disease. Radiographics 17:851 KawashimaA,SandlerCM,CorlFMetal(2001)Imagingofre- nal trauma: comprehensive review. Radiographics 21:557 Kawashima A, Vrtiska T, LeRoy AJ et al (2004) CT Urography. RadioGraphics 24:S35 116 10 Failure of Urinary Drainage: Upper Urinary Kim H, Xu M, Lin Y et al (1999) Renal dysfunction associated with the perioperative use of diclofenac. Anesth Analg 89:999 Kobayashi T, Nishizawa K, Watanabe J et al (2003) Clinical characteristics of ureteral calculi detected by nonenhanced computerized tomography after unclear results of plain ra- diography and ultrasonography. J Urol 170:799 Kravchick S, Bunkin I, Stepnov E et al (2005) Emergency extracorporeal shockwave lithotripsy for acute renal colic caused by upper urinary tract stone. J Endourol 19:1 Larkin GL, Peacock WF 4 th , Pearl SM et al (1999) Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic. Am J Emerg Med 17:6 Lee A, Cooper MC, Craig JC et al (2004) Effects of nonsteroidal anti-inflammatory drugs on post-operative renal function in adults with normal renal function. Cochrane Database Syst Rev 2:CD002765 Lifshitz DA, Lingeman JE (2002) Ureteroscopy as afirst-line intervention for ureteral calculi in pregnancy. J Endourol 16:19 Lowe PP, Roylance J (1976) Transitional cell carcinoma of the kidney. Clin Radiol 27:503 McAleer SJ, Loughlin KR (2004) Nephrolithiasis and pregnancy. Cur Opin Urol 14:123 MokhmaljiH,BraunPM,MartinezPortilloFJetal(2001)Per- cutaneous nephrostomy versus ureteral stents for diversion of hydronephrosis caused by stones: a prospective, randomized clinical trial. J Urol 165:1088 Niall O, Russell J, MacGregor R et al (1999) A comparison of noncontrast computerized tomography with excretory ur- ographyin the assessment of acute flankpain. J Urol 161:534 Nickel JC (2002) Acute pyelonephritis in adults. AUA Updates 21:306 Oktar SÖ, Yucel C, Özdemir H, Karaosmanoglu D (2004) Doppler sonography of renal obstruction: value of venous impedance index measurements. J Ultrasound Med 23:929 Özer C, Yencilek E, Apaydin FD et al (2004) Diagnostic value of renal parenchyma density difference on unenhanced helical computed tomography scan in acutely obstructing ureteral stone disease. Urology 64:223 Pearle MS, Pierce HL, Miller GL et al (1998) Optimal method of urgent decompression of the collecting system for obstruction and infection due to ureteral calculi. J Urol 160:1260 Preminger GM, Assimos DG, Lingeman JE et al (2005) Chapter 1: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. J Urol 173:1991 Rucker CM, Menias CO, Bhalla S (2004) Mimics of renal colic: alternative diagnoses at unenhanced helical CT. Radio- graphics 24:S11 Segura JW, Preminger GM, Assimos DG et al (1997) Ureteral stones clinical guidelines panel summary report on the management of ureteral calculi. The American Urological Association. J Urol 158:1915 Smith RC, Levine J, Dalrymple NC et al (1999) Acute flank pain: a modern approach to diagnosis and management. Se- min Ultrasound CT MR 20:108 Shokeir AA, Shoma AM, Essam A et al(2002) Recoverability of renal function after relief of acute complete ureteral obstruction: clinical prospective study of the role of renal re- sistive index. Urology 59:506 Shokeir AA, Shoma AM, Mosbah A et al (2002) Noncontrast computed tomography in obstructive anuria: a prospective study. Urology 59:861 Shokeir AA, El-Diasty T, Eassa W et al (2004) Diagnosis of ureteral obstruction in patients with compromised renal function: the role of noninvasive imaging modalities. J Urol 171:2303 Simckes AM, Chen SS, Osorio AV et al (1999) Ketorolac-in- duced irreversible renal failure in sickle cell disease: a case report. Pediatr Nephrol 13:63 Tligui M, Khadime MR, Tchala Ket al (2003)Emergency extracorporeal shock wave lithotripsy (ESWL) for obstructing ureteral stones. Eur Urol 43:552 Watterson JD, Girvan AR, Beiko DT et al (2002) Ureteroscopy and holmium:YAG laser lithotripsy: an emerging definitive management strategy for symptomatic ureteral calculi in pregnancy. Urology 60:383 Yoshimura K, Utsunomiya N, Ichioka K et al (2005) Emergency drainage for urosepsis associated with upper urinary tract calculi. J Urol 173:458 Yossepowitch O, Lifshitz DA, Dekel et al (2001) Predicting the success of retrograde stenting for managing ureteral obstruction. J Urol 166:1746 References 117 11 Failure of Urinary Drainage: Lower Tract J.M. Patterson, C.R. Chapple 11.1 Introduction 118 11.2 The Male Patient 118 11.2.1 Introduction 118 11.2.2 Benign Prostatic Hyperplasia 118 11.2.2.1 Pathophysiology 118 11.2.2.2 Epidemiology and Diagnosis 119 11.2.2.3 Lower Urinary Tract Symptoms 121 11.2.2.4 Bladder Outflow Obstruction 121 11.2.2.5 Management 122 11.2.2.6 Pitfalls 123 11.2.3 Malignant Prostatic Disease 123 11.2.3.1 Pathophysiology 123 11.2.3.2 Epidemiology and Diagnosis 123 11.2.3.3 Management 123 11.2.3.4 Pitfalls 124 11.2.4 Urethral Stricture Disease 124 11.2.4.1 Pathophysiology 124 11.2.4.2 Epidemiology and Diagnosis 124 11.2.4.3 Management 125 11.2.4.4 Pitfalls 125 11.2.5 Other Causes of Failure of Lower Urinary Tract Drainage 125 11.2.5.1 Postoperative Urinary Retention 125 11.2.5.2 Urinary Tract Infection 126 11.2.5.3 Urothelial Malignancy 126 11.2.5.4 Neurological Abnormalities 127 11.2.5.5 Trauma 127 11.3 The Female Patient 129 11.3.1 Introduction 129 11.3.2 Urinary Tract Infection 129 11.3.3 Neurological Abnormalities 129 11.3.4 Postsurgery for Stress Incontinence 129 11.3.5 Other Causes of Failure of Lower Urinary Tract Drainage 130 References 130 11.1 Introduction Failure of the lower urinary tract to drain adequately is one of the most common presenting emergencies seen by the practicing urologist. The wide variety of pathol- ogies that can cause this problem needs to be taken into accountwhenassessingthepatient,asitisimportant not to subject the patient to undue risks. In the emergency situation, the most common presenting symptom is that of urinary retention (UR), which itself can present in varied forms. It is often associated with pain and an intense desire to pass urine, most commonly termed acute urinary retention (AUR) (Fitzpatrick and Kirby 2006; Emberton and Anson 1999; Weiss et al. 2001), but it can also be a painless en- tity, sometimes noted by a report of not passing urine for several hours or even days, termed chronic urinary retention (CUR) (Kurasawa et al. 2005; Chooong and Emberton 2000). In some circumstances, presentation is not associated with a full urinary bladder but with a sensation of needing to void when the bladder is empty or near-empty. In some cases this can itself cause significant distress, and along with the discomfort felt by those in AUR, exemplifies the rapidity needed in the assessment and treatment of these patients. Because of the variety of conditions causing UR, it is difficult to design a simple, single algorithm for their management. If the advice in this chapter is followed, however, we hope that the reader will be able to manage effectively the majority of problems seen in everyday practice. 11.2 TheMalePatient 11.2.1 Introduction The vast majority of patients with failure of lower urinary tract drainage seen as emergencies are male. Of these, the largest proportion will present with AUR, either to emergency departments or to primary care phy- sicians. While many patients will have been complain- ing for some time of lower urinary tract symptoms (LUTS) (Abrams and et al. 2002), in some, the emergency presentation is the first indication that they had any functional abnormality of their lower urinary tract. 11.2.2 Benign Prostatic Hyperplasia 11.2.2.1 Pathophysiology Benign prostatic hyperplasia (BPH) is the commonest benign adenoma in the male and develops almost ex- Chapter 11 clusively in the transitional zone of the prostate gland. The growth and development of the prostate is under the influence of testosterone, specifically its active me- tabolite dihydrotestosterone (DHT). After conversion by the enzyme 5- reductase, DHT stimulates andro- gen receptors in the prostate, which results in the pro- duction of growth factors such as epidermal growth factor (EGF). These factors then promote the hyperplasia seen in BPH. It has been postulated that a reduction inapoptosisisalsoinvolvedinthedevelopmentof BPH, by causing an imbalance in the ratio of prolifera- tion and apoptosis and hence leading to glandular hyperplasia. The process also involves an increase in the amountofstromalandsmoothmuscletissueofthe transitional zone. Histologically, initially small stromal nodules are seen in the transitional zone around the urethra, followed by hyperplasia of the glandular struc- tures. These changes are seen in prostates of men as young as 40, and are increasingly prevalent as the population ages. The size of the gland also tends to increase with age, which is in part responsible for the fact that aging male patients experience an increasing incidence of bladder outflow obstruction (BOO), and although there is no statistically significant link between size of prostate and degree of BOO, there is a correlation between size of prostate and the risk of complications of BPH, including AUR and the need for surgical intervention (Anderson et al. 2001; Chute et al. 1991; Fitzpa- trick 2006; Jacobsen et al. 2005; Kirby 2000; Masumori et al. 2003; Thomas et al. 2004). Thesmoothmuscleoftheprostateisundersympa- thetic nervous control, with synaptic release of norepi- nephrine from nerve terminal granules diffusing across the synaptic gap to stimulate large numbers of 1 -adrenoceptors. These are predominantly of the 1A - adrenoceptor subtype, compared with 1B -subtype and 1D -subtype, which are found on blood vessels (causing vasodilatation) and viscera, respectively, and hence antagonists of these receptors are therapeutic targets of interest in the management of BPH. It has been shown that in AUR secondary to BPH, excess -adrenergic re- ceptor stimulation may be causative (Caine et al. 1975; Chapple 2001). Histological BPH tends to progress gradually. Ini- tially, the enlarging transitional zone tissue compresses the surrounding normal prostate tissue, and in time also begins to compress the prostatic urethra. It is this compression that causes a diminishing peak urine flow rate and progressive LUTS. As the caliber of the prostatic urethra is reduced by the hyperplastic prostate, it becomes less distensible, and the hyperplastic gland is also less able to relax to allow normal voiding function. Populationstudieshaveshownthattheprostatein- creasesbyanaverageof1–2cm 3 per year, and in the same series, peak urine flow rates were also seen to di- minishby0.2ml/speryear.However,individualsshow considerable variety, and although in general patients with larger prostate glands tend toward faster rates of growth, the symptoms these patients describe fluctuate greatly. Patients also often find ways of managing their disease so that despite enlarging gland size, their symptoms remain stable (Girman et al. 1999; Roehrborn et al. 2002). Associated with the increasing obstruction caused by the enlarging prostate, several associated morpho- logical changes in the bladder are commonly seen. The detrusor muscle tends to hypertrophyas a consequence of increasing voiding pressures and associated collage- nous infiltration of smooth muscle, which leads to reduced bladder compliance during filling. In a significant proportion of patients, there is evidence of detrusor overactivity causing involuntary bladder contrac- tions, although at present it is unclear whether this is directly related to the BOO or is an unrelated age-de- pendent phenomenon. LUTS therefore seen in patients with BPH causing a degree of BOO (Weiss et al. 2001; Fitzpatrick 2006; Roehrborn et al. 2002; Fong et al. 2005) comprise a combination of storage (frequency, urgency, nocturia) and voiding (hesitancy, intermittency, reduced stream, incomplete emptying) and postmicturition symptoms (postmicturition and terminal dribbling). Withincreasedage,theproblemswithbladderemp- tying tend to progress. Some patients may develop problems fully emptying their bladder, with the development of increased residuals due to an encroaching prostate and worsening obstruction whereby the failing or tiring detrusor is unable to adequately compensate for the obstruction. This can culminate in acute-on- chronicUR,wherethepatientisunabletovoiddespite a volume often in excess of 1.5 l in the bladder.These patients also often have enuresis (so-called overflow incontinence),andinsomecasesthevolumesretained may preclude full recovery of detrusor function (Chapple and Smith 1994). Others may have an episode of AUR, which typically presents as described in Sects. 11.2.2.2 and 11.2.2.4, and requires emergency treatment by catheterization (see Chap. 19, “Surgical Techniques and Percutaneous Procedures”). In some cases, prolonged BOO and the development of residuals will predispose to the formation of bladder stone(s), recurrent urinary tract infections (UTIs; see Sect. 11.2.5.2), and in some cases deterioration of renal function, when the intravesical pressure exceeds the ureteric pressure, hence exerting a back-pressure on the kidneys that can lead to renal failure if left untreated. 11.2.2.2 Epidemiology and Diagnosis It is important to remember that BPH is a pathological diagnosis, and most of the patients seen in practice 11.2 The Male Patient 119 BPH BOOLUTS have clinically enlarged prostate glands but no histological confirmation of BPH. Hence the term “benign prostatic enlargement” (BPE) is more appropriate in those in whom tissue diagnosis is not confirmed. BPH is one of the most prevalent conditions affecting men aged 40 and above. Histological studies have shown features of BPH to be present in the prostate of approximately 60% of men aged 60, and closer to 100% of menaged80andabove.Theonlyclearriskfactorsfor the development of BPH are increasing age and the presence of circulating androgens. Clearly there are specific genetic patterns since histological BPH has been shown to be more prevalent in Afro-Caribbean than Caucasian populations. Asians tend to have a lower incidence still, but this is not maintained in migrato- ry populations, also implying environmental factors in the development of BPH. Clinical BPH seems to run in families, although the genes responsible are yet to be identified. There are three components to the clinical picture of BPH. It has been shown that there is considerable over- lap between BPH and LUTS, and again between BPH and BOO, but they are by no means the same entities. LUTS may or may not be due to BPH, and BOO may or may not be present with BPH and/or LUTS (see Fig.11.1).Whatcanbesaidwithcertaintyisthatpa- tients with BPH, LUTS, and BOO are at greatest risk of disease progression, including episodes of AUR (Weiss et al. 2001; Choong and Emberton 2000; Anderson et al. 2001; Abrams 1997; Kirby and McConnell 2005). Diagnosis is based on clinical history and examination, including an assessment of LUTSanddigital rectal examination (DRE). Although the International Pros- tate Symptom Score (IPSS) (the American Urology As- sociation [AUA] Symptom Score Index) is advocated for the office assessment of LUTS and it is widely used in clinical trials to assess response to treatments (Weiss et al. 1991), in the emergency situation it is of limited applicability. Fig. 11.1. The relationship between prostatic hypertrophy, symptoms and obstruction. Each may exist independently or in combination in each individual patient Acutely, patients presenting with AUR will typically complain of both an intense desire to void and a degree of suprapubic pain (Fitzpatrick and Kirby 2006). They maygiveahistoryofprecedingLUTS,withareduced urine flow rate and a sensation of incomplete bladder emptying correlating best with subsequent progression to AUR. Those with chronic retention will not typically have pain. Some may describe a feeling of fullness, and some may even notice a suprapubic swelling. Usually, however, they present simply with an inability to pass urine, often having not voided for over 24 h. Some of these patients will, however, present in extremis with acute renal failure. These patients are often uremic, and some may have life-threatening electrolyte imbalances including hyperkalemia. Typically, on catheterization, they will have very large residual volumes and subse- quently may have a significant diuresis, which needs careful observation and management with appropriate fluid replacement. In the presence of disturbed renal function, investigations into the state of the upper urinary tracts (typically ultrasound) should also be carried out (see Sect. 11.2.2.5). In the history it is important, as well as asking about LUTS, to exclude any other co-morbidities that could be contributing to the presentation. It is important to exclude neurological disorders, including cerebrovas- cular events, multiple sclerosis (MS), spinal cord injury (SCI), pelvic or perineal trauma, Parkinson’s disease, multisystem atrophy (MSA), and motor neuron disease (MND),andconsideriftheyaretakinganydrugsthat could contribute to dysfunctional voiding (anticholin- ergics,antidepressants,anestheticagents,analgesics). Also,itisimportanttoassessthepatient’sgeneralmed- icalstatetoensurethattheyarenotgoingtocometo any harm as a result of any therapy instigated. Physical examination is performed as a matter of routine. It should include a full cardiorespiratory assessment, neurological examination including cogni- tive state (specifically examining the low lumbar and sacral dermatomes and myotomes to rule out cauda equina syndrome), and examination of the abdomen, paying special attention to the kidneys and the presence or absence of a palpable urinary bladder. Exami- nation of the external genitalia is important to ensure urethral catheterization is not going to be impossible and to identify phimosis or meatal stenosis, as well as to rule out associated infective complications such as epididymitis. If suprapubic catheterization is to be considered, then inspection of the lower abdomen to look for lower midline scars is essential (see Chap. 19, “Sur- gical Techniques and Percutaneous Procedures”). DREisperformedtobothgiveanestimationof prostate size and to exclude malignancy and prostatitis as alternative causes of UR (see also Sects. 11.2.3 and 11.2.5.2). As such it is possibly the most important part of the examination in male patients presenting with 120 11 Failure of Urinary Drainage: Lower Tract failure to empty their bladder. The normal male prostate is less than 20 cm 3 in volume, so BPE can be diag- nosedbytheexperiencedclinicianbasedonDRE alone, although the accuracy of size estimation tends to be very subjective and is certainly reduced in glands bigger than 50 cm 3 . The gland should be symmetrical. Any nodules or irregularity, or a gland that is diffusely firm or asymmetrical could represent malignancy. It is important to note that inflammatory conditions such as prostatitis can also feel firm and irregular, but the difference is that in the acute phase, these will be tender to palpation. In the acute setting, especially in cases presenting with UR, testing for prostate-specific antigen (PSA) is deferred. Although PSA correlates well with both gland sizeinBPHandtumorsizeinprostatecancer,itisalso usually significantly raised in episodes of retention or infection and after instrumentation or examination. (In the nonacute office setting, with patients presenting withLUTSandBPE,itisentirelyreasonabletoperform PSA testing as long as the implications are understood by the patient. Important information can also be obtained in this setting by assessment of peak urine flow andconcurrentassessmentofpostvoidresidualurine volume.) Urinalysis should be performed on the urine obtained immediately after catheterization (if the patient is completely unable to void) and if anything abnormal is seen, the urine should be sent for formal microscopy and culture, and if sexually transmitted infection is suspected, particularly in younger sexually active patients, urineshouldalsobesentforgonorrheaandchlamydia PCR testing (see also Sect. 11.2.5.2). In some cases, patients may present with symptoms suggestive of both AUR and UTI, for example, a few days history of dysuria and offensive smelling urine, with an acute history of inability to pass urine. In these patients, to avoid instrumenting the urinary tract un- necessarily and in the presence of infection, a measure- ment of residual urine volume can be helpful. This is typically carried out using a bedside portable ultrasound bladder scanner (Bladderscan BVI 3000, Ver- athon Inc., Bothel, WA, USA). If the residual volume is very low (less than 150 ml) then the patient should not be catheterized. A course of antibiotics should be com- menced and the patient should only be catheterized if he is unable to void with a more significant urine volume in the bladder. 11.2.2.3 Lower Urinary T ract Symptoms LUTS is a relatively new term coined to lessen the con- fusioncausedbytermssuchasprostatism,symptomatic obstructive uropathy, etc. They comprise three groups of symptoms: storage, voiding, and postmicturition symptoms (Abrams et al. 2002). Storage symptoms include frequency, nocturia, urgency, and urgency incontinence. It is important to differentiate a normal urge to void and urgency, and similarly nocturia from nocturnal polyuria. Voiding symptoms include hesitancy, poor stream, intermittency, straining to void, incomplete bladder emptying, and UR. A case can be made for considering enuresis secondary to chronic retention – overflow incontinence – as both a storage and a voiding disorder. Postmicturition symptoms include terminal and postmicturition dribbling. Clearly these symptoms are not disease-specific and a wide range of other disease states can cause LUTS. These include neurological conditions such as those mentioned above, malignancy (including prostate cancer and urothelial tumors), inflammatory conditions (including UTI, bladder stones, interstitial cystitis), polyuria (diabetes, congestive cardiac failure), and other causes of BOO, including bladder neck or external sphincter dyssynergia, urethral stricture (see Sect. 11.2.4) and severe phimosis. Some symptoms such as a poor urine stream are also found in conditions such as detrusor underactivity or detrusor failure, which do not necessarily have an obstructive component. The role of inflammation within the prostate has also been investigated recently, with several series show- ing that in tissue samples from prostates of patients in AUR,thereismoreinflammationthaninprostateswith BPH/BOO,whichinturnhavemoreinflammationthan normal prostates (Anjum et al. 1998; Roehrborn 2006b; Tuncel et al. 2005). 11.2.2.4 Bladder Outflow Obstruction BOO is a clearly defined urodynamic diagnosis. The most widely accepted diagnosis of obstruction is by the use of the Abrams-Griffiths (AG) number and its associated nomogram. The AGnumber can be derived from conventional cystometry by the following equation: AG number = pDet.Q max –2(Q max ) If the AG number is less than 20, the patient is unob- structed. If the result is between 20 and 40, the result is saidtobeequivocal,whereasifitisover40,thepatient has BOO (Abrams 1997; Chapple and MacDiarmid 2000). In male patients above the age of 40, BOO is typically causedbyBPE,althoughothercausesexist,asoutlined above (other causes of BOO are also discussed in Sect. 11.2.5). In most examples, it tends to be a progressive problem, and serial cystometry in these patients will show progressive increases in voiding pressures with an associated reduction in maximum urine flow rates. In cases caused by BPE, there may be a critical point beyond which the patient is unable to generate a sus- 11.2 The Male Patient 121 tained detrusor contraction sufficient to overcome the outlet resistance, and it is at this point that they may present in AUR. In many cases presenting acutely, however,this information is unknown, and cannot easily be derived in the acute setting. 11.2.2.5 Management Immediate Management Theimmediatemanagementofanypatientpresent- ing with failure to empty their bladder, history and examination aside, is directed to draining the bladder. This is discussed in detail in Chap. 19, “Surgical Techniques and Percutaneous Procedures”. In most cases, the passage of a Foley urethral catheter (under aseptic conditions) is sufficient to bypass the obstruction and establish drainage of the bladder. Typically, the catheter stays in place for at least 24–48 h while long-term management is decided and instigated. In some cases, however, it is not possible to pass a Foley catheter due to the nature of the obstruction. This can be overcome in some patients by using alternative catheters, such as those with a Coud´etip,whichare often able to navigate the obstruction as described in Chap. 19, “Surgical Techniques and Percutaneous Procedures”. If no urethral access is available, then the next option is to proceed to suprapubic cystostomy. In some patients, specifically those with prior lower abdominal surgery, this may need to be carried out under ultrasound guidance. Finally, if this is not possible, then there is no option other than open surgical cystostomy, but this should be regarded as a last resort. If catheterization is successful, and there are no fea- turessuggestiveofhighriskofrecurrentUR,andthe patient has normal renal function, i.e., a diagnosis of “typical” uncomplicated UR secondary to BPE (which should make up approximately 70% patients with AUR), then typically we would proceed to institute pharmacological therapy to aid chances of a successful trial without catheter (TWOC). However, in patients not meeting the above criteria, further investigations are required. In cases where re- nalfunctionisdisturbed,itisappropriatetoperform ultrasonographic examination of the upper tracts to both diagnose obstructive uropathy and exclude any coexisting renal abnormality. In patients with true high-pressureCUR,theremaybeadegreeofhydrone- phrosis, but this should resolve promptly (within 48 h) of catheterization. These patients will typically need definitive bladder drainage, usually via long-term urethral or suprapubic drainage, with surgical intervention as deemed appropriate by TURP. If definitive bladder drainage is not ensured, then the high-pressure CUR will almost invariably recur. Cases of CUR with no hydronephrosis or renal impairment are termed low-pressure CUR and are usually associated with a low-pressure low-flow voiding pat- tern.ThesepatientsfarebadlywithTURP,andarebest managed with clean intermittent self-catheterization (CISC), as the detrusor muscle tends not to recover from its chronically distensible hypercompliant state. CISC is an alternative long-term method of bladder drainage in those patients with BOO who are unfit for surgery, but some patients encounter difficulties with large obstructing prostate glands actually passing the catheters into the bladder. Also, the technique needs to becloselyobservedpriortodischargetothecommuni- ty,assomepatientsfinditmuchharderthanothers. Pharmacotherapy ␣-Antagonists. The receptors responsible for main- taining smooth muscle tone in the prostate are 1A -adrenoceptors, and it is in part due to failure of the prostatic smooth muscle to relax effectively that voiding is obstructed in BOO caused by BPH, leading in some to AUR, possibly as a result of excess stimulation of the - adrenoceptors as a precipitative event. There has been a large shift in recent years in the management of uncomplicated AUR. Previously, the majority of patients would have undergone transure- thral resection of the prostate (TURP) either in the acute setting or several weeks from initial presentation. The advent of -adrenoceptor antagonists has meant that a lot of patients who previously would have undergone surgery can be managed conservatively for a period of time. Standard policy has become starting -antagonists at presentation, at least 24 h prior to TWOC, with very good outcomes. In patients presenting rou- tinely with LUTS suggestive of BPH and BOO, significant symptomatic improvements are seen within 24–48 h of commencing -antagonist therapy (Fitzpa- trick and Kirby 2006; Chapple 2001; Andersson et al. 2002; Chapple 2004; Djavan et al. 2004; Elhilali et al. 2006). Commonly used examples include doxazosin, pra- zosin, terazosin, indoramin (used less than previously), alfuzosin, and tamsulosin. The latter two are associated with fewer systemic side effects. Alfuzosin is to date the only member of this class of drugs to have statistically proven benefits in aiding TWOC in patients with episodes of AUR (Elhilali et al. 2006; Roehrborn 2006a; McNeill et al. 1999), although it is likely that sim- ilarefficacywouldbeexpectedtobepresentforthe other agents in the class. Several studies have shown benefits in terms of pro- longing time to retention or surgery, and recent studies have compounded these benefits by using combination therapy with 5 -reductase inhibitors (McConnell et al. 2003). 122 11 Failure of Urinary Drainage: Lower Tract 5␣-Reductase Inhibitors. The 5 -reductase inhibitors work by inhibiting the enzyme responsible for con- verting testosterone into the more active form DHT. There are two commercially available examples, finasteride and dutasteride. The method of action is to reduce the effect of circulating androgens on the prostate. They effectively reduce growth of the prostate, and have been shown to shrink the glandular component of histological BPH. They are most effective in large prostate glands, but unfortunately the beneficial effects take approximately 4–6 months to appear, so their use in the short term is of limited value. However, if a patient presents with a large volume gland causing BPE and AUR, then adding in a 5 -reductase inhibitor to -antagonist therapy will prolong the time to further episodes of AUR and the need for surgical intervention (McConnell et al. 2003; Andriole et al. 2004; Kaplan et al. 2006). 11.2.2.6 Pitfalls It is important when managing patients with UR associated with BPH that the following points are carefully taken into consideration. 1. Perform DRE to make or confirm diagnosis and exclude malignancy and infection. 2. Measure residual urine prior to catheterization if UTI is suspected. 3. Measure serum creatinine to ensure high-pressure chronic retention is not overlooked, and if present monitor, treat diuresis appropriately, and ensure definitive bladder drainage is in place either via surgery or catheterization. 4. TURP is still appropriate as first-line management of AUR for between 20% and 40% of patients, either acutely or electively. 5. Many patients failing TWOC are not suitable for surgical treatment due to high-risk co-morbidity, and many of these can safely be managed with long-term catheterization, either urethral or suprapubic according to choice and suitability 11.2.3 Malignant Prostatic Disease 11.2.3.1 Pathophysiology Although prostate cancer is increasingly common, the incidence of AUR secondary to malignant disease is very low, probably less than 1% of cases of AUR seen in practice. Having said that, there may be a significant proportion of men, especially those over the age of 70, who present in AUR who have both BPH and undiag- nosed prostate cancer, and most men with prostate cancer will have BPH to a certain extent. Therefore, the mechanisms of BOO are similar to those in BPH, and prepresentation LUTS will also tend to be similar. In some cases, however, the obstruction to voiding will be directly related to local tumor burden causing either compression of the prostatic urethra, or in some cases local invasion into the urethra, seminal vesicles, or ejaculatory ducts, causing mechanical obstruction or stricturing of the prostatic urethra (Anson et al. 1993; Sandhu et al. 1992). The effects on the detrusor are sim- ilartothoseseeninBPH. 11.2.3.2 Epidemiology and Diagnosis The population incidence of prostate cancer has dramatically increased since the advent of PSA testing. It now represents the most common cancer in males, although this includes many cancers not requiring intervention other than monitoring, and is among the leading causes of cancer death in men. This does not mean that the true incidence of prostate cancer is higher, but that more cases are being diagnosed than previously. Most men presenting acutely with symptoms of UR of any cause will most likely have BPH, but several large population studies have shown that a significant proportion of these will have clinically undetectable foci of prostate cancer. This proportion increases dramatically with age (Jo- hansson et al. 2004; Kessler and Albertsen 2003). The patient may present in exactly the same manner as the patient with BPH, i.e., in AUR or less commonly CUR. On initial assessment, it may be evident that they are under investigation for, or being treated for, prostate cancer. DRE may reveal an overtly malignant-feeling prostate, or more commonly a benign-feeling gland. If there is no history of prostate cancer, and the DRE is benign, then one should proceed as per AUR secondary to BPH, and PSA should be checked once voiding is re-established. There is little use in checking PSA acutely, as it will be raised secondary to the epi- sodeofAUR.Ifthereisahistoryofprostatecanceror investigation into the same, or the DRE is suspicious for malignancy, then a different approach should be taken; see Sect. 11.2.3.3. Ifthepatientisknowntohaveprostatecancerthatis being monitored for presumed small-volume organ- confined disease, then episodes of AUR can represent local disease progression, which should alter management, unless this is contrary to the patient’s wishes. 11.2.3.3 Management Management depends on the etiology of the episode of UR. If likely related to BPH rather than prostate cancer, then manage as per BPH above. If the patient is known to have prostate cancer, or the diagnosis is clinically 11.2 The Male Patient 123 [...]... Introduction 132 12.2 12.2.1 12.2.2 12.2 .3 12.2.4 12.2.5 12.2.6 12.2.7 Testis 133 Torsion 133 Extravaginal 133 Intravaginal 133 Presentation 133 Torsion Treatment 134 Torsion of Testicular Appendages 135 Tumors 135 12 .3 Paratesticular Emergencies 136 12 .3. 1 Epididymitis 136 12.4 Spermatocele 137 12.5 Varicocele 138 12.6 Trauma 139 12.7 12.7.1 12.7.2 12.7 .3 12.7.4 Paratesticular Masses 139 Hernia 139 ... Perinephric Hemorrhage Background 1 43 Evaluation 144 Treatment 144 13. 3 13. 3.1 13. 3.2 13. 3 .3 13. 3.4 Hypercalcemia of Malignancy Pathophysiology 144 Presentation 145 Evaluation 145 Treatment 145 142 144 13. 4 Complications of Bacille Calmette-Gu´rin e Therapy 146 13. 4.1 BCG-Related Fever 147 13. 4.2 BCG Sepsis 147 13. 4 .3 BCG-osis 148 13. 5 13. 5.1 13. 5.2 13. 5 .3 Malignant Spinal Cord Compression 148 Presentation... 13. 6 Neutropenia 151 13. 6.1 Febrile Neutropenia 13. 6.1.1 Evaluation 152 13. 6.1.2 Treatment 152 152 13. 7 13. 7.1 13. 7.2 13. 7 .3 13. 7.4 Intractable Bladder Hemorrhage 154 Transitional Cell Carcinoma 154 Hemorrhagic Cystitis 154 Radiation Cystitis 155 Treatment of Intractable Bladder Hemorrhage 157 13. 8 13. 8.1 13. 8.2 13. 8 .3 Ureteral Obstruction Presentation 160 Evaluation 160 Treatment 160 13. 9 13. 9.1 13. 9.2... Emerg Med 23: 544 Nussbaum Blask AR, Bulas D, Shalaby-Rana E, Rushton G, Shao C, Majd M (2002) Color Doppler sonography and scintigraphy of the testis: a prospective, comparative analysis in children with acute scrotal pain Pediatr Emerg Care 18:67 141 Chapter 13 13 Oncologic Emergencies N.-E.B Jacobsen, S.D.W Beck, R.S Foster 13. 1 Introduction 142 13. 2 13. 2.1 13. 2.2 13. 2 .3 Spontaneous Perinephric Hemorrhage... with voiding dysfunction include CVEs, cauda equina syndrome or spinal cord compression, Parkinson’s disease, ShyDrager syndrome (multisystem atrophy), multiple sclerosis (MS), and motor neuron disease (MND) Spinal cord injury also causes long-term voiding dysfunction, but rarely AUR Most patients are, however, managed with an indwelling catheter after the initial injury, until the period of spinal... 160 13. 9 13. 9.1 13. 9.2 13. 9 .3 13. 9.4 Bladder Outlet Obstruction 162 Evaluation 1 63 Treatment 1 63 Urinary Retention After Prostatectomy 164 Urinary Retention After Brachytherapy 164 13. 10 13. 10.1 13. 10.2 13. 10 .3 Respiratory Complications 165 Pulmonary Emboli 165 Bleomycin Toxicity 165 Pulmonary Metastases 166 References 166 159 13. 1 Introduction It has been estimated that genitourinary malignancies will... Postsurgery for Stress Incontinence The aims of stress incontinence surgery is to increase the outlet resistance of the urethra by either injection of bulking agents into the urethral musculature, by elevating the bladder base by colposuspension or by inserting tapes or slings to support the urethra under circumstances of raised abdominal pressures, thereby preventing leakage Unfortunately, in some cases,... perineum Transillumination of the scrotum is valuable 2 Urinalysis 3 Scrotal Ultrasound with Doppler References 12.9 Miscellaneous 12.9.1 Henoch-Schönlein Purpura Henoch-Schönlein purpura (HSP) is a disease that manifests symptoms of purple spots on the skin, joint pain, gastrointestinal symptoms, and glomerulonephritis HSP is a type of hypersensitivity vasculitis and inflammatory response within the... Rhodes T et al (20 03) Natural history of lower urinary tract symptoms in men–result of a longitudinal community-based study in Japan Urology 61:956 McAninch JW, Carroll PR, Jordan GH (1996) Traumatic and reconstructive urology WB Saunders, Philadelphia McConnell JD, Roehrborn CG, Bautista OM et al (20 03) The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression... often normal or suppressed in cases of HHM (Walther et al 1997; Flombaum 2000) Interleukin-6 (IL-6) and prostaglandin (PG), both of which stimulate osteoclast activity, represent additional humoral factors involved in HHM (Papac and Poo-Hwu 1999) 13. 3 Hypercalcemia of Malignancy 13. 3.2 Presentation The most common presenting symptoms of hypercalcemia are nonspecific and include fatigue, anorexia, . 167:2477 References 131 12 Scrotal Emergencies V. M a s t e r 12.1 Introduction 132 12.2 Test i s 133 12.2.1 Torsion 133 12.2.2 Extravaginal 133 12.2 .3 Intravaginal 133 12.2.4 Presentation 133 12.2.5 Torsion. examples include doxazosin, pra- zosin, terazosin, indoramin (used less than previously), alfuzosin, and tamsulosin. The latter two are associated with fewer systemic side effects. Alfuzosin is. combination therapy with 5 -reductase inhibitors (McConnell et al. 20 03) . 122 11 Failure of Urinary Drainage: Lower Tract 5␣-Reductase Inhibitors. The 5 -reductase inhibitors work by inhibiting the enzyme

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