Varicoceles in Children and Adolescence: When and How to Treat?

White blonde little boy around six at the doctor's office. He is with his mom behind him and the doctor is in front of him, examining him and discussing varicoceles in children.

By Andrew J. Kirsch, MD, FAAP, FACS

Physicians and parents alike are challenged by the management of varicoceles in children.  This blog is meant to frame the controversy and educate our patients and families on the current state of the art.  As will soon become obvious, shared decision-making is particularly important when considering the many questions that 15% of the male population and their parents need to consider. The first question below is a big question and charged in controversy.

Do adolescent varicoceles have a progressive harmful impact on male fertility?

 

A graph for varicoceles in children. Five blue text boxes in a row. The first says "adolescent varicoceles", the second says "testicular volume", the third says "semen parameters", the fourth says "hormone alterations", and the fifth says "male fertility". Each box has an arrow pointing to the next, and, to the left is a swooping line that includes all of the boxes with a question mark in the middle.

Determining the effect on future fertility is challenging for a variety of reasons

  • Limitations in obtaining/interpreting semen analysis
  • Unequal differential testicular growth during puberty regardless of varicocele
  • A long lag time between varicocelectomy and attempt at paternity
  • To add to the confusion, there are no current professional guidelines for children and adolescents

There are 2 main debates among expert pediatric urologists.  The first is whether we should treat a varicocele surgically.  Here are the issues:

The debate to treat is supported by these facts:

  • Varicocele is the most common correctable cause of male infertility
  • Corrective surgery (varicocelectomy) improves semen quality

The debate not to treat is also supported by facts:

  • Men with varicoceles father children
  • Semen quality does not always mean there be a successful pregnancy

The second debate focuses on when to treat a varicocele. Here are the pertinent questions:

Do we treat all adolescents with large varicoceles and smaller testis on the same side?  If so, would we overtreat? Or, do we wait and only treat the infertile man trying to start a family? If so, are we too late? Will success be lower? These are the questions that are likely to torment parents of boys with varicoceles.

Here is some data that may help

In the pediatric age patient, the size or volume of the affected (left) testis compared to the normal side is key to helping identify who is at risk for future infertility.  Or is it?  There are many studies on both sides of this long-standing debate. Larger testis volume differences are associated with significantly lower sperm concentration and motility regardless of patient age or varicocele grade.  What is the testis volume loss of boys with varicoceles compared to boys without varicoceles?  A study looking at >400 affected boys compared to 70 normal boys showed that those with grade 3 varicoceles had left testis volume loss at all stages of puberty, but also right testicular volume loss compared to controls. In other words, both testes can be affected.

Many studies show that varicoceles are not progressive – they don’t get worse – and catch-up growth occurs without surgery.  However, in one study of 100 boys with an average age of 15 years, testicular volume differences > 20% lead to 2x odd of a lower total mobile sperm count.  The same study showed total testicular volume (TTV = right + left) <30cc lead to a 4x odds of a lower sperm count.  Almost all studies have shown that there does not appear to be any association between testicular volume loss and hormone abnormalities.

So, we have decided that surgery would be the best approach.  Is there a difference in outcomes?

When deciding upon differences in surgical approach – laparoscopic (Palomo), microscopic, or open groin incision, there is no good data to support one approach over another.  The rates of hydroceles (fluid around testis) or recurrence are generally low (<10%).

Let’s summarize Varicoceles in Children:

The dilemma regarding pediatric varicoceles comes down to these facts:

  • Our tools to identify subfertility are imperfect
  • Your urologist needs to evaluate all meaningful data
    • Testis size (TTV <30cc, TVD >20% )
    • Semen analysis when available
    • Status of “normal” testis
    • Hormone levels (not meaningful in young age)

Parental preference is key.  There’s no doubt about it – shared decision-making is critical to the management of varicoceles.  Advice to parents:  For the majority of boys with varicoceles it makes good sense to follow prospectively and treat conservatively.

Treatment and Prevention of rUTI in Women

White woman with short brown hair sitting with doctor in an office, discussing rUTI.

By Dr. A. Keith Levinson, M.D.

Symptomatic, recurrent lower urinary tract infections (rUTI) in women are a common condition for which best practice guidelines related to treatment and prevention have not been well established. rUTi affects women of all ages and is defined as 2 or more symptomatic episodes in 6 months or 3 episodes in 1 year. Between 20% to 30% of women who have one UTI will have a rUTI, and approximately 25% of these women will have more recurrent episodes.

Symptoms of rUTI may typically include burning with urination, foul smelling urine, urinary urgency, and frequency. Treatment strategies should focus on relieving symptoms while at the same time preventing the overuse of antibiotics, which can cause increased side effects as well as the development of antibiotic resistance.

Who is at risk or rUTI? 

  • For premenopausal women, sexual activity can be associated with rUTI.
  • Birth control products such as nonoxynol-9 spermicide can be a risk factor as well.
  • Lack of estrogen in postmenopausal women can lead to vaginal atrophy, acidic PH changes, and overgrowth of bacteria leading to UTI

What type of work up is needed to treat rUTI?

A urine culture prior to treatment with antibiotics is important to document infection and help determine optimal antibiotic treatment. More complex cases may require renal imaging or cystoscopy.

How is rUTI best treated? 

Short course treatment of 3-5 days is recommended. Preferred first line antibiotics are Nitrofurantoin, Trimethoprim-Sulfa, and Fosfomycin. Fluoroquinilones such as Cipro are discouraged.

rUTI prevention strategies:

Some prevention strategies include lifestyle and behavioral modifications:

  • controlling blood glucose in diabetics is important
  • Sexually active women should avoid spermicide gel use. It is unclear whether voiding after intercourse is useful
  • Avoid unnecessary or prolonged antibiotic use (more than 5 days)
  • maintain adequate hydration

There are also therapeutic interventions, such as antibiotic treatments:

  • The use of antibiotic prophylaxis may sometimes be indicated and can be done in several ways.
    • The use of a single low dose antibiotic immediately after intercourse can be very effective in preventing.
    • Once daily low dose antibiotics for 6-12 months may be required at times and is effective.
    • A patient self start 3 day course of antibiotics can be a convenient way to treat intermittent It is best to get a urine culture prior to starting treatment.

Nonantibiotic therapy: 

While commonly used to prevent rUTI, there is little data to support the use of Cranberry products or D-mannose. The value of oral and vaginal probiotics is questionable.

Vaginal estrogen therapy reduces vaginal PH, reduces bacterial colonization, restores lactobacillus, and reduces rUTI in postmenopausal women. There is no documentation of increased breast cancer risk or rise in serum Estrogen levels. Oral estrogens do not reduce UTI risk.

Methenamine Hippurate :

This is a bacteriostatic agent that increases urinary levels of formaldehyde. It does not promote antibiotic resistance. There is some evidence that using methenamine as prophylaxis may help prevent rUTI and reduce need for prophylactic antibiotics.

Vaccines: 

OM-89 (Uro-Vaxom) is an oral vaccine only available in Europe. It appears to be safe and effective in reducing rUTI. Hopefully, this will available in the U.S. soon

rUTI’s are frustrating for women and can significantly impact quality of life, and daily activities. Identifying underlying risk factors is important. There are potentially preventive measures worth discussing with your doctor.

If you have any more questions about the treatment and prevention of rUTIs in women, click here to schedule an appointment with a Georgia Urology expert today.

Common Questions about Urinary Control after Prostate Surgery

Portrait of happy woman surgeon standing in operating room, ready to work on a patient, ready to discuss Urinary Control after Prostate Surgery.

Expert urologist Dr. John Stites, M.D., answers the most common questions about urinary control after prostate surgery below.

Is it common to have urinary control issues after prostate surgery?

Recovery of urinary control is one of the most common concerns for men undergoing treatment for benign and malignant prostate disorders. While most men experience significant improvement or resolution in urinary symptoms, they remain a common source of stress before and after surgery.

Why do men have problems with urinary control after prostate surgery?

It might seem counter-productive that men may have issues controlling their urination after prostate surgery, especially since many men undergo surgery to treat their urinary symptoms to begin with. The underlying causes of these symptoms aren’t limited to the prostate itself; often other structures such as the bladder or urethra can undergo changes after surgery.

For example, a man may undergo surgery to reduce obstruction from his prostate gland so that he may more easily pass urine. Before surgery, his bladder must push harder than usual to pass urine beyond his prostate gland. When this obstruction is surgically removed, however, the bladder must adjust to changes caused by surgery. An unusual urge to urinate with or without leakage may occur during this recovery.

What changes in my urinary control can I expect after prostate surgery?

Individual changes after surgery cannot always be predicted, but there are many tools to help us identify those at risk for urinary control issues after surgery. Before surgery is performed, testing may be needed to determine the functional and structural characteristics of the urinary tract. This information helps us identify men at risk for postoperative urinary control issues.

Who is at higher risk for problems with urinary control after prostate surgery?

More invasive procedures (such as radical prostatectomy for prostate cancer) carry a higher risk for urinary control issues postoperatively. Many factors can influence urinary control after surgery, including underlying medical conditions, medications, diet, and daily activity. Many of these factors are modifiable, and improvement is often achieved by a comprehensive and motivated approach.

It is important to ask your urologist about urinary control when considering prostate surgery, and to discuss pre-existing urinary control issues. Patient education and motivation are among the most important factors in improving urinary control after prostate surgery.

If you have any additional questions regarding urinary control after prostate surgery, click here to contact our expert team.

How to Prevent and Manage STDs

Urologist tells patient that they have STDs.

By Dr. Darrell J. Carmen, M.D., F.A.C.S.

Unfortunately, sexually transmitted diseases (STDs) are common.

Chlamydia is the most commonly reported STD in the U.S. It’s spread mostly by vaginal or anal sex, but you can get it through oral sex, too. Sometimes you’ll notice an odd discharge from your vagina or penis, or pain or burning when you urinate. But only about 25% of women and 50% of men get symptoms. Some other common STDs are gonorrhea, genital herpes, human papillomavirus (HPV), syphilis, trichomoniasis, and HIV/AIDS human immunodeficiency virus or acquired immunodeficiency syndrome.

Not all conditions that affect the sex organs are considered STDs, and some are not related to sex at all. Some are sexually-associated, meaning that they aren’t transmitted during sex, but occur as a result of it. A urinary tract infection can occur because of irritation from intercourse but is not an STD.

How to Prevent STDs

To prevent getting a sexually transmitted disease, always avoid sex with anyone who has genital sores, a rash, discharge, or other symptoms. The only time unprotected sex is safe is if you and your partner have sex only with each other, and if it’s been at least six months since you each tested negative for STDs. Otherwise, you should:

  • Use latex condoms every time you have sex. Condoms are not 100% effective at preventing disease or pregnancy. However, they are extremely effective if used properly.
  • If you use a lubricant, make sure it’s water-based.
  • Avoid sharing towels or underclothing.
  • Shower before and after intercourse.
  • Get a vaccination for hepatitis B. This is a series of three shots.
  • Get tested for HIV.
  • If you have a problem with drug or alcohol abuse, get help. People who are drunk or on drugs often fail to have safe sex.
  • Consider that not having sex is the only sure way to prevent STDs.

It was once thought that using condoms with nonoxynol-9 helped to prevent STDs by killing the organisms that can cause disease. Current research shows that doing so also irritates a woman’s vagina and cervix and may increase the risk of an STD infection. New recommendations are to avoid using condoms with nonoxynol-9.

How to Manage STDs

  • Stop having sex until you see a doctor and are treated. Most tests to diagnose STDs can be obtained from a voided urine or blood specimen. urethral swab not needed.
  • Follow your doctor’s instructions for treatment.
  • Use condoms whenever you have sex, especially with new partners.
  • Don’t resume having sex unless your doctor says it’s OK.
  • Return to your doctor to get rechecked.
  • Be sure your sex partner or partners also are treated.
  • Use latex condoms every time you have sex. If you use a lubricant, make sure it’s water-based.

If you have any more questions about STDs from our experts, click here to contact us today.

Urinary Tract Fistula After Hysterectomy: What are the Options?

Urologist is speaking with patient about Urinary Tract Fistula.

By Dr. Lambda Msezane

Severe continuous leakage of urine is a rare complication after routine hysterectomy. This can be a sign of a fistula between the bladder, vaginal wall, or the ureter and the vaginal wall. A fistula is an abnormal tract that forms between two areas of the body.

Keep reading below to learn more about urinary tract fistula from a Georgia Urology expert.

What are the Symptoms of Urinary Tract Fistula?

The main symptom of a urinary tract fistula to the vagina is nonstop leakage of urine. Associated symptoms include abdominal pain or fever if urine collects in the abdomen. The type of leakage associated with a fistula is more severe than the typical stress and urge incontinence that can also occur. In most cases, it requires surgical intervention to repair this complication.

How is Urinary Tract Fistula Treated?

In the past, women would have to wait 6 weeks to 3 months before repairs could be attempted after a traditional open hysterectomy. This is due to the number of adhesions or scar tissue that forms after surgery. This was especially true because the signs of fistula can be delayed for a week to 10 days as the tract forms and this is when the adhesions start to become difficult. A woman would have to wait either with a catheter, a nephrostomy tube (a tube into the kidney through the back), or deal with the leakage until the repair could be attempted.  

Robotic-assisted surgery has changed the urologist’s approach to this life-changing complication. Due to the robotic arms and 10x magnification camera, we are allowed the ability to access the pelvis with great visualization and dexterity. This is done through small incisions as opposed to a large midline incision. Urologists no longer need to wait months to repair the fistula. We can either re-implant the ureter to move it away from the fistula tract in the case of a ureterovaginal fistula or dissect the bladder away from the vaginal wall in the case of a vesicovaginal fistula.

What is Recovery Like for Treating Urinary Tract Fistula?

Since the surgery is minimally invasive, the patient can go home the next day and can be completely healed in about 4 weeks. This significantly shortens the recovery time compared to open repair. An indwelling catheter to drain the bladder and a ureteral stent may be needed postoperatively for a short period of time.  

Although initially devasting, the repair of vesicovaginal or ureterovaginal fistula post hysterectomy can be performed in a timely fashion thanks to the robotic approach. Women with this complication can return to their normal life with a smaller incision, less pain and recovery time, and most importantly no further severe leakage of urine.

If you have any more questions about this urological condition or treatment options, get in contact with Georgia Urology physicians by clicking here.  

Can a Child with UTIs have Reflux?

Urologist and child patient are happy after finishing up treatments for VUR and UTIs.

By Dr. Michael Garcia-Roig

Urinary tract infections (UTI) can occur in children, as well as adults. This happens when bacteria normally living in the bladder grows out of control and irritate the bladder’s lining, causing symptoms like painful urination, having to run to the bathroom often, urine accidents, or blood in the urine.

If you find yourself asking can a child get a UTI or VUR, keep reading below.

What Causes UTIs in Children?

In young kids, a few common behaviors can cause urinary infections. Specific behaviors that put kids at risk for UTI are not urinating often, not drinking enough liquids, and ignoring a full bladder or the urge to urinate withholding behaviors like the “pee-pee dance” or holding the genitals. Constipation also plays a huge role in UTI’s, especially in kids. It doesn’t take long for the rectum to get full in kids. With the pelvis being small, the full rectum can get in the way of the nerve signals to the brain, or in the worst cases, it can even directly pinch the bladder and make it hard to empty.

What Causes VUR?

Normally, urine made by the kidneys comes down a small tube, called the ureter, to the bladder. This is intended to be a one-way trip- once urine makes it to the bladder it can’t go back up to the kidney. Vesicoureteral reflux, or VUR, happens when urine can freely flow back and forth between the bladder and kidney. In some people, this back and forth flow of urine can cause a small bladder infection to quickly turn into a miserable kidney infection. In kids with VUR who get kidney infections, especially those that get lots of them, long term kidney damage can happen.

Sometimes the bacteria causing a bladder UTI can make their way up to the kidney, causing a kidney infection, also called pyelonephritis. These kidney infections can be very severe in some children and are most commonly signaled by a UTI with a fever. There are several reasons why kids can get pyelonephritis, but this article will focus on the most common reason, vesicoureteral reflux.

How Do You Treat UTIs in Children?

The first step in managing a UTI is to get a urine sample before starting antibiotics to see what is causing the problem and what is the best medicine. Urine samples after antibiotics may give a false negative result. In kids who are not potty trained, this is done by passing a catheter into the bladder to get a clean sample of urine. Specimen collection bags that can be taped to the groin are good for checking the urine for a lot of things, but not for checking for urinary infection as they are very, very unreliable.

For children 2-24 months old with their first febrile UTI, the American Academy of Pediatrics recommends getting an ultrasound of the kidneys and bladder to rule out major kidney problems. Further testing is not recommended unless problems are noted on the ultrasound, or until a second UTI with fever happens.  At that time, your doctor will order a test called a voiding cystourethrogram, or VCUG, to look for vesicoureteral reflux or VUR. Vesicoureteral reflux is the medical way of saying urine goes from the bladder up to the kidneys. The VCUG is done by passing a small tube, called a catheter, through the urethra and into the bladder. The bladder is filled with x-ray contrast and x-rays are taken to see how the bladder and urethra look, and if contrast stays in the bladder, or goes up to the kidneys.

How Do You Treat Vesicoureteral Reflux in Children?

If vesicoureteral reflux is found after a febrile UTI, there are a few options for treatment. Sometimes a daily low dose antibiotic is started to prevent more kidney infections. In some kids, VUR will go away on its own as he or she grows. This usually takes one, two, or more years and a VCUG is repeated every year until its gone. Your doctor may be able to estimate the likelihood it will resolve in your child.

VUR can also be corrected with surgery. There are two basic approaches to surgery. First involves passing a small camera into the bladder through the urethra, and a small needle is used to inject a sugar-based substance called Deflux just under the ureter. In our hands, this stops reflux and infections 90-95% of the time. Kids go home the same day, there are no cuts, and there is typically little discomfort. Another way to fix VUR is called ureteral reimplantation. This surgery tucks the ureter into the side of the bladder and stops reflux and infections 95% of the time. It requires a small cut near the pubic bone, and kids stay in the hospital 1-2 nights. In some kids, a surgical robot can also be used to do ureteral reimplantation with similar outcomes and less pain.

There isn’t a one size fits all treatment for VUR, as each of these treatment options has its own pros and cons. What does need to happen is the prevention of kidney infections. Your doctor will go over options with you in detail to help find the best way to treat your child.

If you’d like any additional information on the question can a child get a UTI or VUR, click here to contact any of Georgia Urology’s expert pediatric urologists.

Penile Fracture: A True Emergency

Man with penile fracture suffering in bed.

Most people have never heard or experienced a penile fracture. However, the penis can “fracture”, even if there is no bone in the penis.

Georgia Urology expert Dr. Zisholtz explains this urology phenomenon and the experience he’s had correcting these.

How Does a Penis Break?

During sex, and as the penis becomes erect, the pressure inside the two cylinders begins to rise. The pressure during sex inside the penis can increase to over 200mm of mercury in a healthy man.

However, if during sexual activity the penis accidentally hits the woman’s pubic bone, the immediate pressure is magnified and the cylinders can rupture.

What Does a Penile Fracture Feel Like?

Usually, there is a loud popping sound and sudden pain. The erection suddenly disappears, as all the pressure is relieved by the blood escaping into the soft tissues. Sometimes, the blood may also go directly into the urethra, resulting in bleeding from the tip of the penis.

How Do You Treat a Penile Fracture?

Ice and pressure should be applied, and emergency consultation is advised. The best treatment is to repair the rupture and any other area that was damaged. With repair of the fracture and drainage, there’s a much better chance for the gentleman to maintain his future sexual capacity.

Does Georgia Urology Treat Penile Fracture?

Over the last two months, I’ve had two patients with severe “fractures”. Both were operated on, repaired, and/or drained. I’m happy to report both are back in action!

If you have any more questions or concerns about this urological issue, contact the experts at Georgia Urology to make an appointment.

Learn About Extracorporeal Shock Wave Lithotripsy

An example of why Extracorporeal Shock Wave Lithotripsy is needed.

By Dr. Jerry Yuan, M.D.

Extracorporeal Shock Wave lithotripsy, or ESWL, has revolutionized kidney stone treatment since its introduction in the mid-1980s. Now, it’s the most commonly employed treatment for kidney stones in the US.

Learn more about this treatment Georgia Urology is proud to offer for our patients below.

What is Extracorporeal Shock Wave Lithotripsy?

The inspiration of ESWL derived from aeronautical science, where the shock wave at the leading edge of airplane wings at high speed was studied. In short, with ESWL, a source of shock wave (electromagnetic, as in our Dornier device) is focused and directed at the stone. Various physical forces are then optimized to induce stone fragmentation with the goal of reducing sizable stone to smaller entities to allow for spontaneous passage. Refinements over the last 30 years allow the current generation of lithotripters to precisely focus the shock wave energy and minimize unintended collateral injury.

When Would Someone Receive Extracorporeal Shock Wave Lithotripsy?

Most kidney stones maybe considered for ESWL. A typically patient is one who has a medium size stone in the ureter tube and is deemed unlikely to pass expeditiously as seen in the 1st radiograph.

How Does Extracorporeal Shock Wave Lithotripsy Work?

Usually, a patient is scheduled as an outpatient and is positioned on the treatment table under light general anesthesia.

Our office preparing patient for Extracorporeal Shock Wave Lithotripsy.

General anesthesia is recommended given the procedure is somewhat painful. Additionally, since precise shock wave delivery is paramount, patient movements as those under twilight anesthesia tend to compromise the overall success. The stone is then localized and positioned in the “crosshair” prior to initiation of treatment and will be monitored throughout the session.

An xray for an example of crosshair of Extracorporeal Shock Wave Lithotripsy.

What Should be Considered Before Receiving Extracorporeal Shock Wave Lithotripsy?

Large stones greater than 1 cm, especially the rather hard stones, may require multiple sessions. This is. Because the energy required for these stones surpasses the amount the body can tolerate at a single session. Large and difficult to break stones may be more expediently treated by surgical stone removal whereby an endoscopic portal is introduced via the flank to allow for direct visualization and stone fragmentation and removal (PCNL).

Stones located in the lower ureter may also be treated via mini endoscopes via the urethra for direct basket removal or laser lithotripsy with high success rate.

A patient about to receive Extracorporeal Shock Wave Lithotripsy.

ESWL is one of several modalities at our disposal to allow for effective stone treatment. Each treatment has its pros, cons, and limitations. The best approach is by no means universal and is individually based taking into many factors such as size, location, chemical makeup or hardness, and patient preference. If you have any questions about this procedure, contact the urology experts at Georgia Urology.

Aquablation TURP: A Revolutionizing Robotic Surgery for BPH

Urologists perform Aquablation on patient.

By Dr. Brent A. Sharpe, M.D.

As urologists, it’s not often we get to witness something in our careers that revolutionizes the way we do things. The first time I ever experienced this phenomenon was after performing robotic surgery for prostate cancer. Within 10 years, more 95% of all prostate cancer surgeries in the US were performed using the robotic system.

However, I thought this would be my one and only opportunity to witness this moment of change in our field, but I was wrong. Now, there is a new revolutionizing robotic surgery for men with benign prostate hyperplasia, BPH, which may make other forms of transurethral surgery obsolete.

What is Benign Prostate Hyperplasia?

BPH is a very common condition in which the prostate grows and obstructs the flow of urine. Over 70% of men in their 60’s have BPH. It can have many effects on the urinary stream such as a decreased flow, difficulty starting the flow, starting and stopping during urination, frequency, urgency, and commonly getting up at night to use the bathroom.

How Has Benign Prostate Hyperplasia Typically Been Treated?

The mainstays of therapy are daily medications, in office procedures or transurethral surgery called TURP. A TURP removes the obstructive prostate tissue by using a heat-based system, such as laser or cautery, to resect the tissue. Historically, it also has been associated with significant complications and the need for repeat operations. One of the main reasons for this is that the surgery must perform the manually and without any guidance of how much tissue needs to be removed because there is no real time imaging to guide the surgery. Now enter Aquablation TURP!

What is Aquablation TURP?

Aquablation TURP by Procept BioRobotics utilizes the clarity of real-time multidimensional imaging, the accuracy of an autonomous robot, and the power of a heat-free water jet to produce a more reliable and predictable surgery. The use of real-time ultrasound permits for key structures to be identified to allow for normal sexual function and continence, as well as to determine the exact size and shape of the prostate.

The automatic robotic device allows for faster and more predictable removal of tissue. Finally, by not using heat energy during the procedure there is a reduction in the typical complications associated with standard TURP.

Is Aquablation TURP Successful?

In two multicenter, multinational studies, Aquablation has been proven to be safe, effective and consistent. The procedure times are drastically reduced and, in some case, may be reduced by more than 50%. Historically, a large prostate gland could take 2 hours to remove tissue, but in these studies, the Aquablation TURP took only 38 minutes.

Georgia Urology is the first practice in three surrounding states to use this new and exciting surgical robot to perform Aquablation TURP for men with BPH. Currently, Drs. Brent A. Sharpe and Lewis Kriteman have performed nearly 10 procedures with all patients experiencing a significant reduction in their BPH symptoms and are extremely satisfied. For more information, you can contact Drs. Sharpe and Kriteman at 678-205-8387 or click here to schedule an appointment.

Medical Management of Kidney Stones

patient with kidney stones learning the best practice for the medical management of kidney stones

By Dr. Edan Y. Shapiro, M.D.

If you have questions about the medical management of kidney stones, you’re not alone. That’s why Georgia Urology’s Dr. Edan Shapiro is answering all your most pressing questions about the medical management of kidney stones.

What are Kidney Stones?

Kidney stones are one of the most common reasons for patient visits to our urology offices. In fact, one out of every 11 people will be affected by a kidney stone at some point in their lifetime. This represents a dramatic increase in the prevalence from just a few decades ago.

Additionally, stones can affect both men and women equally. Individuals with symptomatic stone pain often require visits to the emergency room and may even require a surgical procedure.

How Can I Prevent Them?

While the technologies to treat stones in a minimally invasive way are constantly evolving, perhaps an even more important focus has been on the medical management of stone disease. That is to say, how do we prevent stone formation in the first place? This is especially important considering that nearly ½ of people who get stones will have a recurrence.

Aside from the recommendation that all stone formers should drink at least 2.5 liters of fluid daily, there is no single dietary change or medicine to take that will improve every single person’s chance of getting a stone. This is despite some of the misinformation on the internet. Adding lemon juice or removing sweet tea from the diet may not help everyone!

Rather, it is important to determine the individual person’s risk profile, and then use that information to tailor a strategy. Make sure to ask your urologist about this.

What is a 24-hour Urine and Why Should I Consider Getting One?

Whenever a passed stone is available to test, it is a good idea to send that stone for analysis and determine its composition. But this represents only a small piece of the puzzle and often fails to tell the entire story. Perhaps more important is performing additional metabolic testing, which is recommended for any recurrent stone former, or even for the first-time stone former who is interested in minimizing their future risk.

This mainstay of this additional testing is a 24-hour urine collection, which is then analyzed for at least 10 different factors that are involved with stone formation. These factors collectively determine the patient’s risk and occasionally uncover an underlying systemic issue (such as a problem with the parathyroid gland or an issue with the kidney). By determining what factors are higher or lower than they should be, it is then possible to make recommendations to favorably alter those levels in a way that minimizes risk.

This is usually first attempted with diet modifications, though pharmacologic therapies also exist. For example, someone who is found to have high levels of calcium in their urine should be encouraged to limit their sodium intake; despite what many may assume, they do NOT need to alter their actual calcium intake. When this dietary change is not enough, certain types of pills can then be prescribed to further lower the level of calcium in the urine. Similar recommendations exist for people with other common scenarios, such as having elevated oxalate levels, elevated uric acid levels, or for people with low urinary citrate levels.

Will I be Able to Prevent all Stones?

Even the best of plans cannot be 100% foolproof. Therefore, it is important to repeat the 24-hour urine test after the implementation of a treatment strategy and then with some regularity. This way, the strategies can be constantly improved, setting up the person for success. It is also important to make sure to get periodic follow-up imaging (e.g. ultrasound, x-ray, CAT scans) to look for interval stone formation or growth.

If you have any more questions about the medical management of kidney stones for the Georgia Urology team, click here to schedule an appointment with any of our expert urologists.