© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
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Barkin ET AL.
stone as it leaves the kidney will often determine the
level of the pain. The pain starts in the flank and back
just under the ribs and radiates around the side and
down onto the pelvis and testicle in a man or to the
labia/vagina in a woman. It is usually accompanied
by nausea and vomiting. Commonly, the patient has
microscopic or gross hematuria.
If the patient has fever with the renal colic and the
work up suggests there is significant hydronephrosis,
intervention is necessary to drain this “closed space”
or the patient could sustain gram-negative septicemia
and shock.
If the stone is in the lower ureter, near the “uretero-
vesicle junction,” the patient may have significant
frequency and urgency with small urine volumes and
no sign of infection. This is a detrusor reflex, since the
stone irritates the lower ureter.
The diagnosis can often bemadewith an ultrasound
of the kidneys, ureters, and bladder (KUB), a urinalysis,
a plain KUB x-ray and, if available, a CT scan of the
kidneys, ureters, and bladder (CTKUB or CT urogram).
Patients are given an analgesic for the pain of a
ureteral stone, and are prescribed an antibiotic if they
have any elevation in their temperature that could
indicate at least partial obstruction of the ureter. Since
the ureter consists of smooth muscle, guidelines also
suggest prescribing an alpha-blocker for men and
women who have ureteral colic due to a ureteral
stone. Alpha-blockers that selectively relax the
ureteral smooth muscle could reduce ureteral spasms,
which would help relieve the pain. At the same time,
the ureteral lumen could expand, allowing earlier
expulsion of the stone.
A recent paper by Gupta et al
17
compared the
commonly used alpha-blocker tamsulosin with the
newer alpha 1A selective alpha-blocker silodosin
for the management of ureteric stones. The study
showed that the stone expulsion rate was 58% for the
tamsulosin group and 82% for the silodosin group, and
the time to expulsion was 19.5 days with tamsulosin
versus 12.5 days with silodosin.
With this new therapeutic approach, almost 2% of
patients with renal colic who present to an emergency
department and are prescribed alpha-blockers may be
spared from further interventions such as endoscopic
manipulation.
Castration-treatment-induced bone loss
Prostate cancer is the number one diagnosed cancer
and the third leading cause of cancer-related death,
in men in North America. For a further discussion on
prostate cancer, see Gomella et al.
18
Some patientswithprostate cancermay not desire or
tolerate certain prostate cancer curative treatments, or
if the primary curative treatment fails, these men may
be offered surgical or medical castration. By reducing
the production and/or the uptake of testosterone into
the prostate or the cancer areas, the cancer can shrink
or lie dormant or be controlled for many years. This
approach is analogous to “removing the fuel from the
fire.” Prostate cancer will grow under the stimulus
of testosterone, so by excluding testosterone, in many
cases we can slow or prevent the progression of
prostate cancer. The medications include luteinizing
hormone-releasing hormone (LHRH) analogues or
antagonists and the anti-androgens.
Testosterone is necessary for many physiologic
functions in men. By preventing its production, men
who receive medical castration are at increased risk for
conditions such as osteoporosis, metabolic syndrome,
diabetes, obesity, muscle loss, and hot flashes.
19
Medications to treat osteoporosis include
bisphosphonates such as zoledronic acid and the
human monoclonal antibody denosumab. The latter
drug prevents RANK-ligand (RANKL)- RANK
interaction and thereby inhibits the development of
bone demineralization. To help protect bones from
the effects of low or absent testosterone, patients are
also prescribed vitamin D and calcium and advised to
exercise and stop smoking.
Careful management of existing or newly diagnosed
diabetes in the setting of hormonal ablation is very
important, since the expected biochemical response
to diabetic medications might be altered.
Awareness of the potential side effects of
medications that may not only increase survival and
delay progression of prostate cancer allows clinicians
to provide support to patients to help them maintain
a better quality-of-life.
Conclusion
The PCP is often the first-line assessor of many
urgent and non-urgent, malignant or benign urologic
conditions. With this article, based on the literature
and years of front-line experience, the authors hope
that PCPs will better understand how to diagnose and
manage some common urologic presentations and
know when to refer a patient to a urologist.
Disclosures
Dr. Jack Barkin has been a clinical investigator, speaker
and medical advisory board member and consultant
forAbbott, Lilly, Bayer, Paladin, Actavis, AstraZeneca,
