Kidney Stones (Nephrolithiasis)
Kidney stones are crystals of mineral that form in the kidney. Close to 90% of stones are calcium salts of various type of which calcium oxalate is the most common. The rest are usually a mixture of calcium oxalate and calcium phosphate. About 10% of the stones are uric acid stones. Some stones are associated with urinary infection called magnesium ammonium phosphate stone (or struvite). In fact, stones are mentioned even in the Hippocratic Oath. Some stones do not cause any symptoms. Some stones pass down from the kidney causing blockage, pressure build up of urine, severe pain, and sometimes even damage to the kidney and can cause potentially life threatening infections.

Why me?
About 1 out 200 people will form a kidney stone this year, totaling more than 1 million cases in the United States. About 80% of the stone will pass spontaneously, while 20% will need treatment. Some people inherit a tendency to form stones from their parents. If a person forms a stone, the metabolic condition is ripe for another stone formation such that there is a 50% chance of another stone in 5 to 10 years without preventive measures. Risk factors for stone formation include low fluid intake/dehydration, blockage of urinary tract, and certain medical conditions such as gout and intestinal disease.

What about the unbearable pain?
The usual condition that leads to diagnosis of kidney stone is a pain attack from a stone passing through the ureter, called renal colic. Sometimes, a kidney stone may present as blood in the urine. Pain caused by a kidney stone is usually very sudden in onset, very intense, and usually continuous without letting up with intermittent exacerbation. Typically, one cannot find any comfortable position no matter what. Typically, a kidney stone pain begins in the back but pain then may move around the side to the groin area.

Treatment
If treatment is necessary, the goal is to completely remove the stone. Treatment depends on the location and size of the stone, and anatomy of the urinary tract. Generally speaking, a lithotripsy also known as ESWL (extracorporeal shockwave lithotripsy) is the preferred treatment for upper urinary tract stones of moderate size, 1.5 cm or less. Lithotripsy is the break up (tripsy) of a stone (litho). The goal is to completely “pulverize” the stone to such tiny fragments so as to allow passage out of the body without any problem. However, it is possible to have the fragment cause obstruction and resulting pain. The overall success rate of ESWL is about 85%. If a stone is closer to the bladder in the ureter and it needs treatment, the preferred treatment is to completely remove the stone from the body by using a basket extraction with or without a laser to break up the stone. This is done by using a special scope that can fit in the delicate ureter called a ureteroscope. Either way, a general anesthetic is required for both treatments. Sometimes, the kidney stone is so large that ESWL is not sufficient. In these situations, there is a special procedure called percutaneous nephrostolithotomy which means removal of the stone through an opening into the kidney via skin. This is something that is indicated for a stone that is larger and more complicated in terms of anatomy. A careful discussion should take place about all of these matters with your urologist so that you can make an informed decision.

After the stone, then what?
However a stone is treated, the stone fragments or stone itself should be analyzed of its chemical make up to determine the type of the stone. This is an important “piece of the puzzle” to determine future kidney stone formation risk. Dr. Lim strongly recommends to all patients that they consider also doing some additional blood and urine tests to discover and treat any treatable condition to prevent more stone formation. Dr. Lim also recommends that a patient undergo 24 hour urine collection, looking at the volume of urine per day, amount of calcium, oxalate, citrate, and uric acid mineral content per 24 hour excretion, to better understand and modify either the diet or the fluid intake to decrease the stone formation likelihood. Also, it is important to keep a regular check up with your urologist, like once a year, to keep “an eye on the matter.” This reminds a patient of the importance of preventive care and habits as it relates to kidney stone risk. This has been called “stone clinic effect.”

Urinary Tract Infections
Urinary tract infections (UTIs) are among the most common problems representing more than 6 million office visits per year in the United States. Most UTIs are initially treated by primary-care physicians, but under certain conditions urologists are asked to assist with further evaluation and management. UTIs affect both men and women of all ages. Pediatric urinary tract infections are often associated with discoverable anatomical risk factors and are evaluated differently. Pediatric febrile urinary tract infections require anatomical imaging of both the upper urinary tract (that is kidney) and lower urinary tract (that is bladder). Sometimes, a procedural correction of discovered abnormalities is required in pediatric UTIs. Infections become more common in later years due to increased voiding issues seen in aging males. Post-menopausal females are more apt to get urinary infections due to loss of the protective layer in vaginal tissue due to female hormone deficiency. On the other hand, women have an increased incidence at young age after the onset of sexual activity. It is estimated that 20 to 50% of all women will experience a UTI at some time during their lifetime.

Symptoms of a UTI
Urinary tract infections are either uncomplicated or complicated, based on the absence or presence of structural or functional abnormalities of the urinary tract. It is essential to identify patients with risk factors for complicated UTIs. Some of these factors could be a stone, obstruction of urinary tract, bladder dysfunction, improper elimination of feces and urine, and underlying neuropathy from diabetes. In contrast, a simple bacterial cystitis (bladder infection) in a sexually active female would be considered uncomplicated UTI. Recurrent infections are defined as more than 2 in 6 months, or more than 3 in a year. The vast majority of recurrent infections are reinfections, and the minority is due to persistence of the same infection. Another way of classifying infections is “bladder” infection versus “kidney” infections. Typically, bladder infections are associated with irritative symptoms such as increased frequency of need to urinate, urgent need to urinate, having to get up to urinate at night, and on occasion, blood in the urine or very strong odor in the urine. However, the kidney level infection can be associated with fever, defined as temperature greater than 101 Fahrenheit or 38 degree Celsius. A person with kidney infection may have chills or backache. Backache is due to the fact that the kidneys are below the rib cage in upper part of the back, in the back side of the body.

How do I check for a UTI?
Although one can suspect a urinary tract infection, based on many of the symptoms, the only true way a urinary tract infection can be confirmed is with a urinalysis and a urine culture. In complicated urinary tract infections, evaluation of the urinary tract by an imaging and sometimes a cystoscopy or bladder x-ray is necessary. In male patients, a history of bladder symptoms such as slowing of urine stream, difficulty starting or maintaining urine stream and feeling of the bladder not being completely empty, may signify either prostate disease such as enlargement, also known as benign prostate hypertrophy or BPH, or urethral stricture (narrowing) from prior urethral infection such as Gonorrhea or Chlamydia infection. These symptoms are also called obstructive voiding symptoms.

Treatment Considerations
Treatment centers on the use of antibiotic therapy and good hydration. The act of urination itself is the best defense against a urinary tract infection. Therefore, drinking plenty of fluids and urinating on a regular basis can be used as a prevention strategy as well. In those women who note a clear association between sexual intercourse and UTI, a dose of antibiotic either immediately before or after coitus can significantly reduce the rate of reinfections. Women with relatively frequent UTIs may benefit from continuous prophylactic antibiotic therapy either daily or by every other day regimen. Those patients with complicated urinary tract infections due to some kind of structural abnormality may need corrective surgery for these conditions including sometimes a treatment of a kidney stone that may be colonized by bacteria.

I noticed blood in my urine. Should I be alarmed?
Finding blood in urine is one of the most dramatic and often ominous signs that alarm a patient. Sometimes, however, a patient may not know that he or she has too much blood in their urine except for the analysis of the urine (urinalysis) that is ordered by the physician. The type that anybody can see as bloody urine is called gross or macroscopic hematuria. The type that is discovered during urinalysis only is called microscopic hematuria, defined as being greater than 3 red blood cells per high powered microscopic field. Patients with gross hematuria are more likely to have an identifiable source of bleeding, whereas an evaluation is often negative in patients with only microscopic hematuria. Hematuria is often intermittent, and the resolution of bleeding should never serve as a reason to omit an evaluation. An exception to this general premise is hematuria associated with culture-proven urinary tract infection in women, which resolves after the infection is completely resolved.

What measures do I have to consider?
In general, hematuria in younger patients is usually caused by benign conditions, such as a stone or infection. Bleeding in older males is often the result of prostate enlargement and urinary infection accounts for most benign cases of bleeding in adult females. Hematuria associated with flank pain or suprapubic pain is often benign in nature, whereas painless hematuria should be considered a sign of cancer until proved otherwise. Age greater than 40 years and smoking are risk factors for malignancy of the bladder and trigger a need to consider a cystoscopy (look into bladder). If there is evidence of kidney function loss, spillage of protein in urine, or finding of abnormally shaped red cells, evaluation for kidney medical disease should be pursued. Otherwise, the evaluation of the entire urinary tract should be done from beginning of kidney blood supply to the tip of the urinary opening. This usually involves an imaging of the kidney of some type and a cystoscopy. Sometimes in patients who are at high risk for bladder cancer, such as smokers or those with occupational exposure to chemicals or dyes (benzene or aromatic amines), a special test called UroVysion™ involving a technique called Fluorescence In Situ Hybridization or FISH may be useful.

Prostate Problems
The prostate is uniquely a male organ that causes many problems to aging male hosts. The enlargement of the prostate (benign prostate hypertrophy or BPH) is a process that happens gradually with age. The exact cause is still debated but it is at least partially due to the male hormone called DHT (dihydrotestosterone). The part of the prostate that undergoes this progressive growth is located in the central portion of the prostate surrounding the male urethra just below the urinary bladder. It causes symptoms such as having to urinate at night (nocturia), severe urgency to urinate, slowing of urine stream, interrupted urine stream, having to strain to urinate, and sometimes the feeling of not being empty despite having urinated. Besides these symptoms, other problems can be due to BPH, such as blood in the urine, recurrent urinary tract infections, prostate infection, inability to urinate at all, back up of urine to the bladder/kidneys, and even kidney failure. Recognition, evaluation and effective treatment of BPH is essential to men’s health.

Prostate cancer facts
In contrast to BPH, prostate cancer tends to arise from the outer part of the prostate. Other than skin cancer, prostate cancer is the most common form of cancer in men in the United States, and the second leading cause of male cancer mortality. The American Cancer Society estimated that during 2002 about 189,000 new cases of prostate cancer was diagnosed in the United States. One man in six will be diagnosed with prostate cancer during his lifetime, according to ACS estimates, but only one man in 32 will die of this disease. The incidence of prostate cancer increases with age. More than 70% of all prostate cancers are diagnosed in men over age 65. African-American men have the highest prostate cancer incidence rates in the world.

What is a PSA test?
A simple blood test called PSA (prostate specific antigen) can be used to detect cancer of the prostate early. The PSA test traditionally has been considered normal within the reference range of 0 to 4.0 ng/ml. A man with a PSA between 4 to 10 has about 1 in 5 chance of being diagnosed with cancer of the prostate. A PSA over 10 could signify about 50% chance of being diagnosed with prostate cancer. However, a normal PSA test does not guarantee the absence of prostate cancer. Sometimes, a man can have a normal PSA and can still be diagnosed with prostate cancer purely based on the digital prostate examination.

When should I start getting my prostate checked?
An annual digital examination of the prostate is recommended for any man over the age of 50 years and 40 years for any man with a family history of prostate cancer and of African-American heritage. The rate of change of PSA is an important indicator of possible prostate cancer, called PSA velocity. The ratio between the PSA and the prostate volume is also helpful, called PSA density. For patients whose PSA ranges between 4 to 10, using the so-called percent free PSA can further prognosticate the likelihood of truly harboring prostate cancer.

Other alternative
Using a test called PCA3 Plus® can be helpful. The urine sample collected after a prostate examination is tested for genetic expression of the PCA3 gene, which is specific for prostate cancer. However, the only true method to diagnose or rule out prostate cancer is a prostate biopsy. For further information about PCA3, please visit the Bostwick Laboratories website.

Treatments to consider
The most widely used treatment is alpha-blocker therapy to relax the smooth muscles of the prostate. More recently, another class of medicine called 5 alpha reductase inhibitors has been used, which actually halts the progressive enlargement of the prostate and reverses the growth, shrinking the prostate by about 1/3 of its volume. There are many procedural treatments of the prostate. The traditional standard is a procedure called Transurethral Resection of Prostate or TURP. Recently, laser vaporization or enucleation of the prostate has been popularized. Other minimally invasive therapy includes heating the prostate, called Transurethral Microwave Thermotherapy (TUMT). Pros and cons of these different treatments is uniquely personal and requires a full discussion with your urologist.

Problem: Undescended Testis Pediatric Inguinal Hernia Hypospadias Penile abnormalities Vesicoureteral Reflux