Transcript: Your Urology Questions - Answered!

Liz Rohr:
I think, and I don't know if you experienced this as a newer physician, but I remember, especially as a newer grad, I'd be like, there's microscopic hematuria. I need to deal with this right now.

Well, hey there, it's Liz Rohr from Real World NP, and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

In this week's episode, I interviewed Dr. Joseph Acquaye. He is a urologist, and we sourced questions from the Real World NP community about urology, the general theme being what you wish primary care providers knew, and then what we would like to ask you.

So we talked about things like microscopic hematuria, BPH, incontinence, and erectile dysfunction, so many different things, and things that he wishes we knew, and pet peeves, and it was so much fun. So I can't wait for you to watch or listen to this episode. If you haven't already, please do grab the ultimate resource guide for the new NP. Head over to realworldnp.com/guide. You'll get these episodes sent straight to your inbox every week with notes from me, patient stories, and bonuses I really just don't share anywhere else. Without further ado, here is my interview.

Thank you so much for being here. Can you introduce yourself?

Joseph Acquaye:
All right. Thank you for having me, first of all. My name is Dr. Joseph Acquaye. I'm a urologist with Well Star at the Douglasville, Georgia location. And yeah, I'm looking forward to this opportunity to discuss some of the common urologic issues that probably come up on the primary care landscape, and talk about some do's and don'ts, and recommendations for things that we get consulted on pretty routinely.

Liz Rohr:
Awesome. Awesome. I'm so, so, so happy you're here. So the first question I have, which is the theme of this whole interview, is maybe a place to start is, what do you wish primary care providers knew in the context of urology?

Joseph Acquaye:
Okay, so I think there's three general categories where there might be some, not a knowledge gap, but something that would make it a little more streamlined, in terms of what gets sent to urology. So the three areas are renal masses, microscopic hematuria, and PSA screening. So I think I'll start with renal masses. So we get a lot of consults on renal masses. A lot of times, they're incidentally discovered. Let's say somebody gets in a car accident or gets imaging for something else, and a renal mass shows up on their CT scan or their ultrasound. And I get sent those patients a lot, and a lot of times, I think that a lot of the providers who are sending those patients over haven't looked at the patient's prior imaging to realize that that renal mass that we're being consulted on has been there for 10 years. So I get this consult, just like, oh, yeah, you mean that one that you had back in 2009?

Yeah, it's the same size, nothing to do. So I think that's a common one, and I think that's an easy fix. Anytime you get imaging, especially with a new mass, just make sure it's actually new. Take a look at the previous imaging, and make sure it's stable. We don't really get excited about renal masses until they hit three or four centimeters, and if you've been stable for years, then it's probably benign. So really nothing to do on that regard. So I do think that's a good, easy thing to think about whenever you get a consult for renal masses. And on the same vein, I guess I could also talk about kidney stones.

Liz Rohr:
Yes. Oh, yes. I forgot to mention that. There was so many questions about kidney stones. All the gems and pearls, please.

Joseph Acquaye:
Yeah, so I think a basic principle about kidney stones is that, of course, you can have kidney stones that are actually just in the kidney, not obstructing, just kind of sitting there, and you can have kidney stones in a ureter, which are obstructing and obviously going to cause some symptoms. So I get a lot of consults on non-obstructing kidney stones, and if a person has a kidney stone that's just been sitting in their kidney, and the same principle, it may have been there for years and years, and it's just hanging out, no reason to consult. It gets a little more nuanced when the stone is large. Let's say it's bigger than one centimeter. Then it's more reasonable to send the consult over.

The reason is because a lot of times, they're going to require some treatment for that stone potentially in the future, because they're more likely to become symptomatic or be a nidus for recurrence infections. So that's one thing to kind of think about. But if it's a three-millimeter, non-obstructing stone, it's just been sitting there, it came up incidentally on imaging, no reason to send it to urology. Because we were going to send it right back and be like, yeah, he has a kidney stone.

Liz Rohr:
We fixed him.

Joseph Acquaye:
Yeah, that'll be $300, please. No, but really nothing to do there. With those stones, though, I can get some of the rationale behind sending them, because when you do a urinalysis on a person with obstructing stone, there's usually going to be blood there, some microscopic hematuria. But yeah, and I guess that's a good segue to the next thing, microscopic hematuria.

Liz Rohr:
Yes, hundred percent.

Joseph Acquaye:
Microscopic hematuria, of course, depending on how you're measuring it, they have the dip stick, it'll say one plus, two plus, three plus, or trace. And we usually don't really get excited anything below two plus. So if it's trace or one plus, that says something. You say, hey, let's retest it in six weeks and see if the UA shows anything. If it's persistently positive or it's increased, then of course I think it's reasonable to send over a consult. But if it's very trace amounts, no reason to send that, and especially if it's in the setting of an infection, or they just started Plavix, or there's a clear immunology for what could cause the microscopic hematuria. You can delay that consult and just repeat a UA in six weeks. And if it's still positive, then yeah, send it over. We'll do the workup. For microscopic hematuria, the workup entails some type of upper tract imaging. So typically a CT, a urogram. It also entails cystoscopy.

And then, a lot of times, we'll do the workup, it's negative, and we'll send them back. And they may have persistent hematuria, but I wouldn't get too excited about it. But let's say two years down the road after the negative workup, if they still have it, then it's reasonable to say, okay, maybe you should talk to the urologist again. And sometimes we'll do a repeat workup, and then sometimes we're like, yeah, there's nothing. It's probably a renal cause, because a lot of it can have renal cause, and some people are just going to have microscopic hematuria. I'd say first things first, make sure there's not another plausible explanation, and if it's trace or one plus, just repeat the UA in a couple of weeks to make sure that nothing's going on.

Liz Rohr:
Yeah, I was going to say, I so appreciate that. Because I think, and I don't know if you experienced this experienced this as a newer physician, but I remember especially as a newer grad, I'd be like, there's microscopic hematuria. I need to deal with this right now, and especially in the context of BPH, because that's pretty common. If you have BPH, you can have that hematuria, especially with small amounts. And I'd be like, well, what do I do? Should I send them even though they have BPH? What if they have bladder cancer on top of it? I just got really in my head about it. So it's helpful to hear that from your perspective of, it really is that time-based thing. And I had a lot of questions about the workup before sending for hematuria, because it sounds like imaging is a really big part of it. But also, do you recommend anything aside from urinalysis? Do you do urine cytologies? What are your thoughts about that?

Joseph Acquaye:
Yeah, the most updated guidelines do not recommend cytology for microscopic hematuria. If they have gross hematuria, then yeah, you go full tilt, which is the cytology, the CTU, and then referring for cytoscopy. So different practices work differently. So I know a lot of people refer, and they don't want to do the CTU before they refer, because they want the urologist to do everything. But some people will do the CTU before they send them to urology. That way, once they see the urologist, we just say, okay, we looked at your upper tract imaging, and we'll go do a cystoscopy. Now sometimes, obviously, the upper tract imaging shows something really obvious, like a bladder mass or a huge stone, or a bladder stone. So in those cases, it kind of streamlined the process. Because we're not going to do a cystoscopy on somebody who has a clear cause. We might just, for sample,

Liz Rohr:
I'm sorry, what did you... Schedule them for what?

Joseph Acquaye:
Oh, for the OR. Especially... the bladder mass, would just go straight to OR. We're not going to go through a whole thing. But yeah, the big delineation is microscopic hematuria is just imaging and cytoscopy. Gross hematuria is imaging, cystoscopy, and a cytology.

Liz Rohr:
Cool.

Joseph Acquaye:
That's the big difference.

Liz Rohr:
That's so helpful. Thank you so much. Yeah, and I think there's a ton of questions with most specialties too, of what imaging do we get first? Because just for context, for newer clinician listeners and viewers, that's one of the discomforts people have is, should I order this test that I don't really know how to interpret? Because I don't do it all the time, versus is it much more helpful to have the imaging. You go to the appointment, and then they've saved so much time. And that's my personal philosophy of practice. In primary care, you have to know all the specialties a little bit, and so that's my philosophy typically with patients is, hey, we're going to do this imaging. We'll see what the results are, but this is to help the urologist once we get there.

Joseph Acquaye:
Yeah, and I think I'm not bothered either way. I know practices work differently, and people have different comfort levels. But as long as consult is indicated, if we have to order the imaging or order the imaging, it's not too much of a burden there. But yeah, I think that's just a matter of how you're going to do it, how you're going to approach it.

Liz Rohr:
Yeah. And I have a question. Do you have any pet peeves of primary care providers? You can also take a pass if you don't want to answer. We're not going to come for you.

Joseph Acquaye:
That's my segue to the next one, which is PSA screening.

Liz Rohr:
Oh yes, yes, yes, yes, yes, yes. Sorry, would you get to the third one? Okay, go ahead.

Joseph Acquaye:
I would say that's probably my pet peeve about consults. So I know that the guidelines are kind of fluctuating, but generally, the guidelines say start PSA screening at 50, or at age of 10 years before the first-degree relative had it. So for example, if their dad had it at 50, then the person will start screening at 40, and then the consensus is to stop at 70. Or sometimes, you have the discussion with the patient, if they want to continue screening. So my pet peeve is when I get the 85-year-old patient who just has a PSA, and the PSA is sky high, and now we have to have this weird discussion with this person... screening in the first place. And of course, they're nervous, because they have a PSA. They might have a PSA of 20 something, and now it's like, what do you want to do?

Are you going to biopsy? Are you going to go that route? You're going to need surgery. You're going to need radiation. And a lot of times, you can convince them that, hey, you're 85. Prostate cancer is slow-growing. It's probably not going to be have any clinical significance for 10 years. But a lot of times, they don't want to hear that. They're like, oh, if you need to do something, and these workups we do for prostate cancer, not benign like prostate biopsy, the side effects or the outcomes can be pretty deadly, especially if they get an infection for example. Because a prostate infection is not a small thing, and especially with an older person who has less of a reserve.

So I think that I always encourage PCP, so just stick to the guidelines when it comes to PSA screening. I know it's obviously a little hard, because a lot of times, it's part of a big panel. So they're just doing the yearly physical, and it's just a checklist. On the checklist is a PSA. But after 70, unless they're a really healthy 70, you have 70-year-olds who are super healthy, low comorbidity, yeah, it's reasonable to keep screening them. But if it's a guy with a 1000 comorbidities and prostate cancer's probably low on the things that's probably going to kill him, I would not continue to screen them, because it does basically start this whole cascade of events that continue for the rest of their life, when they could have just avoided that altogether.

Liz Rohr:
Totally. People had questions also about thresholds for PSA referrals. Do you have any thoughts about that, of any abnormals come to see you, or do we do a trend over time? I feel like it's been so contentious with PSA back and forth over the years.

Joseph Acquaye:
No, I think it's reasonable, just as long as it's elevated. Above four, send it over, because when you send it over, we have the discussion for the subsequent discussion. We say, hey, your PSA is mildly elevated. Here are your options. We can do a biopsy and just go aggressive. We can do an MRI if you want to skip that, and see if there's any lesions that are potentially amenable to biopsy, or we can just watch your PSA and repeat it again in six months. And a lot of patients will opt for one of those three. So we can have that discussion. I don't mind having that discussion with the patient, because it is a more nuanced urology discussion. But sending them over is fine. I think just use the lab thresholds. If it's four, then yeah, use four as your threshold, and above four, just send them over.

Sometimes, though, you can be prudent, because let's say they've been like zero, 0.1, 0.3, and all of a sudden they have a PSA of 20. And then, okay, did you do something different, or is something going on? Or is there a lab error? For example, patients who take up bike riding, and they have perineal pressure, their PSA will be falsely elevated. Oh wow. Or if they recently had a catheter placed, or if they recently had an infection, all of these can falsely elevate PSA.

So sometimes I'll get these crazy consults, and it's like, oh yes, PSA just jumped to 20. I think he's got metastatic prostate cancer, and I'll just repeat the PSA, and it's zero again. So if there's a weird outlier, I'll be like, okay, that's kind of weird. I'll check it again, three months or something, just to make sure it's not anything, or not like. Say six weeks, and if you send those, that's fine, but that's just something to keep in mind, especially if it's not making sense in your head as to why this PSA trend is off. But no, I think it's reasonable just to send the consult over, and we'll have that discussion, what they want to do next.

Liz Rohr:
I so appreciate you sharing that, because I think that I really want to highlight, especially for newer clinicians adjusting, that we don't have to do it all, and we don't in fact have the time. And we don't have the nuanced knowledge to have those conversations, whether it's NP or MD in primary care. And I think that it's just really helpful to hear what's on the other side. I think I'm such a nosy, curious person to begin with, that I just want to hang out in all the specialties, and ooh, what happens. So the fact that that's going to happen when you get there, when the patients get there, I can actually explain to them, this is the process to expect, even if I don't have the full nuanced conversation about PSA. So it's cool.

So I have some other questions from people. So you kind of touched about stones. So primarily, when it comes to kidney stones, I guess the question is, people want to know about urology versus nephrology. Because I know there's bladder stones, there's ureter stones, there's kidney stones. What are your thoughts about urology and nephrology from that perspective?

Joseph Acquaye:
So nephrology is not going to do anything for your kidney stones.

Liz Rohr:
So just to clear up that myth there. Just because it's in the kidneys, they don't own it.

Joseph Acquaye:
They're just going to send it to urology. So like I said, I think the major delineation you have to be concerned about, is this an obstructing stone? And of course, if it is, patient will know, and that's something you send to urology, right? If it's a non-obstructing stone that's just in a kidney, once again, the same principle with renal masses. See if you can see any evidence of this stone on previous imaging, if it's available. If you are going to do any type of stone workup where you have a question about a stone, don't order an ultrasound. I don't know how to read those for stones, and they're not really helpful. A CT non-contrast is good. That's another pet peeve, when people order ultrasounds for stones, because I always have to order a CT, because I say, yeah, maybe you can see a stone. Recommend CT.

So you're just doing imaging for no reason, for no reason. But I think with kidney stones, they're under urology's purview, and if they're obstructing or if they're really big, like I said, over one centimeter, reasonable to send it over. If it's a small little punctate stone, and even if they're bilateral, and they're not having any symptoms, no reason to send that, because we're not going to do anything about it. There's no indication to go and clear out the stones in the kidney, because oftentimes you'll do more harm than benefit. The only... would be if they're having recurrence infections for example, or if they're having a lot of pain. Because there are people who will have flank pain without an obstructing stone when the stones are big, and sometimes it's like, okay, I've worked this person up, and let's just send them to urology. And they're annoying consults, but we understand that you're really kind of pushed to that point.

Liz Rohr:
Totally. Do you have any guidance also about ordering the CT urogram?

Joseph Acquaye:
So usually imaging centers have a protocol. So as long as you put CT urogram, or you put it in the con, because it's with IV contrast. So let's say you don't have CT urogram. You can just put CT with IV contrast, and in the comments, write urogram. The imaging center should know what that entails. And a CT urogram would only be for a hematuria workup. If it's a stone, we simply just put a CT non-con.

Liz Rohr:
Yeah, that's awesome. I'm trying to think of the other questions we had. I think a really big one is about, I think three big ones. And we can pick and choose depending on time, but I think there's erectile dysfunction, BPH, and incontinence. I think there's a lot of questions. The main thing is, there's resources to consult about how to best manage those, but then I think there's questions a lot of people have with especially those conditions of, at what point, when you find an enlarged prostate, if it's a first diagnosis, is that something that the primary care provider should be managing, versus do you refer to urology right away? Like I said, let's start with maybe enlarged prostate to start, and then we'll talk about the other topics.

Joseph Acquaye:
So I think it depends on the initial presentation. So there's the guy with enlarged prostate who's like, yeah, I'm having a little trouble with peeing, and my stream's a little bit weaker. And then there's the guy who comes in with urinary retention, and he's got 1000 liters in his bladder. So obviously that second guy, that should be an immediate referral to urology, because his retention is going to need something more than just medical treatment. You can initiate medical treatment, but that person's going to need to be seen by urology. The other guy who's like, yeah, I have a little trouble peeing, and I'd want to try something. It's reasonable to start Flomax, and it's... side effect profile. You basically just have to tell them, hey, take it at nighttime, because it's going to make you kind of drowsy potentially. And then you always have to let the men know about the retrograde ejaculation, because it's always a number one thing.

Liz Rohr:
Oh, wow. No, I was not aware. Thank you for telling us.

Joseph Acquaye:
So that one, basically, because it relaxes the muscle of the prostate, that's where the ejaculatory ducts are as well. So some of the ejaculate is actually just going to dribble out, and some will go back to bladder. And then suddenly like, hey, what's going on? So you just let them know that's a potential side effect. But aside from that, it's a pretty minimal side effect profile. So I always start them, and have them follow up in three months, and then if at three months, like, yeah, it works great, I'm like, all right, see you in a year with regards to that issue.

Now there is the guy who, let's say you have a patient who's already been on Flomax. He's done it for years, and he is like, yeah, it was working before. Now it's not working too much. It's not necessarily FDA guidelines, but sometimes people will just double up the dose, so you can go some 0.8, but sometimes you can also just send them to urology. Because at that point, we're going to have the discussion about, okay, listen, we can increase your dose. We can add finasteride, or we can talk about minimally invasive treatment options.

Because of course, people know about the TURP, which is the traditional way of relieving obstruction. But now there's so much more less invasive procedures that patients can take, and they're catered towards these patients who are on medications but still not happy with where their symptoms are at. And especially with the younger guys, they don't want to be put on finasteride, which is the other agent because of the hormonal side effects, decreased libido, erectile dysfunction, things like that. Those guys, I'll see them like, yeah, I've been on Flomax for years, and it's not really working. And I try doubling up, and still not really working. So I'll talk to those guys and say, okay, well, listen, we can give you surgery, and that might actually get you off medications altogether. And we have all these options available in addition to the traditional TURP, which is still the gold standard.

Liz Rohr:
Yeah, and I guess I have a question about that too. When should we be more concerned about some sort of underlying prostate cancer when somebody's coming in for enlarged prostate?

Joseph Acquaye:
So it's very uncommon to actually see that as a presentation, because if you have an enlarged prostate and it's secondary to cancer, that means your cancer is very locally advanced. And they would typically... the back pain, and their PSA would probably be sky high. But part of the initial workup for BPH is always to get a PSA, right? So obviously, if you get a PSA that's super high, then you're like, all right, well, I'm sending you to urology, because there might be something else underlying this. But if they come the first time, they have an enlarged prostate with a PSA within normal limits, then it's fine.

Liz Rohr:
Cool, cool. That's awesome. Yeah. And so, I think there's a similar question about erectile dysfunction in terms of workup versus treatment in primary care versus sending to urology. What are your thoughts about that?

Joseph Acquaye:
Yeah, so I think there's a lot of different philosophies, because some clinics just work different. Some clinics are like, listen, I don't have times to deal with ED, so I'm going to send you over. But like I said, similar, Viagra and Cialis. They both have a similar, relatively mild side effect profile. The headaches, the congestion, some of the color vision abnormalities, those are all transient, and usually they resolve where patients are not doing any, I think you can operate on the principle of, listen, I'm going to start you on the middle dose of two pills, and you can go up to four or not. And then you can go both ways. I get some patients who are coming for new ED a lot, and it's like, whatever, I'll see them. But it's not wrong with seeing them in primary care.

The part do definitely refer them as if they've tried oral therapies already and they're like, hey, this isn't working. And then of course, we'll talk to them about escalating medical therapies, things like ICI, intracavernosal injections. Obviously, on the more invasive side, we can talk about surgeries like penile prosthesis, and we can talk about adjunct tools like penile pumps or things like that.

Liz Rohr:
Yeah, definitely. And I should have prefaced before we started recording that I also like using interviews to ask and also the whole channel to ask questions that I feel dumb asking, but if I feel dumb, then other people probably feel dumb too. So I have a, well it's not necessarily a dumb question, but it's been a while since I've worked up erectile dysfunction. And also, there's a lot of questions about using testosterone, checking for low testosterone, and managing that. I know endocrine manages that. Is that something that you also manage, in terms of the hormonal?

Joseph Acquaye:
Yep. So urology or endocrine can manage hypogonadism, because testosterone can be part of the original erectile dysfunctional workup. And... back low, you tell the patient it's just one reading. The full hypogonadism workup entails two testosterones, and you also test for some central labs, like FSH, LH, prolactin, estrogen, to see if you can delineate where the source of the hypogonadism is. But I think that if you're going to do a workup, the basic workup is just getting a testosterone, and that's at least basic thing. But yeah, if they're going to be on testosterone replacement, there's kind of two scenarios I see. So one scenario is that patient gets a testosterone drawn. It's low. After the initial low testosterone, they're sent to me, and I basically take over.

And then there's the other scenario, where patient gets initial low testosterone. They come to me. I do additional workup. They get started on testosterone replacement, and then they want to go back to their primary care, because they're like, hey, I don't do the injections, if they go that route, myself, but it's also a lot of work for me to come to here. So can my... do them?

And it's basically just a standard dose. Patients do it at home, but some patients don't want to do it. So in that scenario, they end back there, and if they end up back there, then it's just a matter of monitoring the testosterone. And it's pretty simple. You just want the testosterone to be above 300. You don't want to overshoot it too much. So if you're going in the thousands, you should probably just cut down their dose to the next lowest, and you're... their hematocrit to make sure it doesn't get too high. Because if it does get too high, then they'll need to donate blood, or phlebotomy, or something like that just to get some... So yeah, I think it all depends on how your practice is structured. A lot of patients, they'll just stick with us for their testosterone replacement. Some will stick with their primary care, and others still will go with endocrine.

Liz Rohr:
Totally. That's helpful. That's super helpful. Is there a cutoff for you? And again, it's been such a long time with testosterone, low testosterone treatment for me, and not many people, but what is the cutoff? Is there a guideline cutoff, or a personal kind of anecdotal cutoff for the hematocrit elevations?

Joseph Acquaye:
The guideline cutoff is 300, and it's total testosterone. So there's free testosterone. There's binded testosterone. All those don't matter. It's just the total testosterone is what you use, and 300 is the cutoff. And they basically standardize it to simplify things.

Liz Rohr:
Oh, the hematocrit, though, the hematocrit and hemoglobin, is there a cutoff for that one?

Joseph Acquaye:
Just as long as it's not above 55, I'd say, because the upper limit is like 54 or something. So yeah, anything above 55, it's getting a little bit thick, and you just want to let them know, hey, you might need to go donate some blood or something like that.

Liz Rohr:
That's pretty easy way to do it, if they're eligible. Absolutely. Absolutely. So, sorry, go ahead.

Joseph Acquaye:
I was just saying it's not going to cost you money, and you're helping somebody out.

Liz Rohr:
Totally. So I have a question about incontinence and urinary frequency, especially in cis female patients. Any thoughts, pearls, all the things, anything you want to say, I welcome it. As you maybe can tell, urology is not a strong area for me, so I have all the questions.

Joseph Acquaye:
Listen, I'm a urologist, and sometimes that stuff's hard for me. But yeah, incontinence is a tough one, because obviously, first of all, you have to delineate what type of incontinence you're dealing with. So is it stress incontinence? Obviously, the people who cough, and laugh, and leak and things like that. Is it overactive bladder or urge incontinence? Those are people who just get the urge out of nowhere, can't make it to the bathroom in time. Is it a little bit of both, where you can have mixed incontinence? And then of course, in the rare case, you can have overflow incontinence, where the person is in retention, and they have so much in their bladder, it's just leaking out. So I'd say obviously urge incontinence, and stress incontinence, and mixed are what we see more commonly. And I think especially when you're trying to figure out and parse out the symptoms, you have to ask the patient straight up like, hey, listen, I can't treat anything.

What's bothering you the most? Is it the stress, or is it the urge? That's what we're going to focus on.

Liz Rohr:
Yes.

Joseph Acquaye:
So that's one thing you want to delineate. So urge is the one that's a lot more common in women, and the first thing you do before thinking about all the pharmacological interventions is, what's your daily fluid intake? So do you drink a lot of caffeine? Do you drink a lot of carbonated beverages? Do you drink a lot of citrusy things? Do you eat a lot of dark chocolates? Do you eat a lot of spicy foods? These are all triggers for people who tend to have these overactive bladders, and you'll be surprised. You'll talk to a patient, like, yeah, I drink five cups of coffee a day. I drink two energy drinks, and I have. I'm like, okay, stop, and I think you're going to have improvement.

And usually that's enough. They'll be like, hey, yeah, I'm not urinating 12 times a day, or not throughout the night. Yeah, of course. The other thing is, I always ask about their bowel habits, because patients are extremely constipated and the rectum is in very close proximity to the bladder outlet. So if you're constipated, you're not emptying your bladder well, and if you're not emptying your bladder well, it's always going to feel like you have to pee all the time. You'd be surprised about some of the... Oh, yeah, you know what? I only have a bowel movement every three, four days. And I'm like, yeah, that's not good. So I usually just have them start on some kind of bowel regimen, like some MiraLax, and Colace, and a lot of times, that helps as well. So you always start with the behavioral stuff, give them a month or two. Some people do diaries and things, and you can do those.

But I just find patients generally tend not to do them, unless it's a very studious patient. You know them. You're like, okay, is this person going to do it? Otherwise I'm just like, this and this, do this stuff. We'll check it in a month and see where you're at. Now, if after a month, they've done all this stuff and they've actually really done it, and they're still having overactivity, then you can say, listen, I'm going to send you to urology, or listen, I'm going to start you on a basic anticholinergic then or something. But that being said, especially if they're an older patient, it can get kind of complicated trying to choose an anticholinergic, because it's always a fall risk. So if you have any, just send them over to urology, kind of start from there. Because at that point, we might say, okay, maybe you need some upper tract imaging, or maybe you need a cytoscopy. And we'll kind of delineate the symptoms a little bit more, and then be like, okay, well, you're older, so we'll start you on this anticholinergic agent, or this one at this dose.

So if it gets there, then just send them over. But if it's a younger person, you're not concerned about fall risk, oxybutynin is always a reasonable first line to start with, and if that doesn't work, just send them over to urology. Go from there. And of course you counsel them, if you're going to do an anticholinergic. They're going to get dry eyes, dry mouth, potential constipation, and there's a fall risk. And there's also a small risk of retention, because it can work too well.

Liz Rohr:
I see. I see. Totally, totally. And I was going to ask you, how closely do you work with either urogynecology or pelvic floor therapists? Do you have much overlap with them, or how does that work?

Joseph Acquaye:
Wouldn't say overlap. Let's say for example, person has incontinence, or a bulge, and they're diagnosed with prolapse. Then it's a urogynecologist, because I don't do prolapse surgeries. There are some urologists that will take on them, because a urogynecologist is basically either a urologist who did that fellowship, or a gynecologist who did that fellowship. So they do repairs. So that's when I kind of interact with them, when a patient has a prolapse in the setting of stress incontinence. Conversely, with pelvic floor physical therapy, I definitely send patients there, those patients who have dysfunctional voiding. So the patients, they have a lot of pain during intercourse. They can't seem to void, and their symptoms are kind of vague, but seems like there's some tightness down there. Those are people I just send to pelvic floor PT. So think you're never going to lose something by sending somebody to pelvic floor PT, if you suspect that's what's going on.

Liz Rohr:
Definitely. Cool. So I guess one, two last follow up questions, two last questions, rather. So one is about recurrent UTIs. So I recently just did an episode on the channel, if people haven't seen it yet, definitely can check that out, of the foundational pieces about that. But just generally speaking, anything you want to share about that? I think there was questions especially about recurrent UTIs in postmenopausal cis female patients. So what are your thoughts about that?

Joseph Acquaye:
Yeah, so you're kind of alluding to the fact that after menopause, it is more common for cis female patients to get recurrence infections. And if you think about the pathophysiology, what's going on, essentially, of course, most infections are from E. coli, derived from the GI system. And what happens is, the GI, the E. coli from there traverse the vagina and make their way into the bladder, and then it causes infections. And normally that doesn't happen too frequently, because your vaginal lining is thick and a good natural barrier. But of course, with menopause, and atrophic vaginitis, that barrier gets very thin, makes it easier for the bacteria to traverse. And then after, you start getting into this cycle of recurrence infections.

So almost every post menopausal cis female patient I see gets started on vaginal estrogen, and I say, hey, use vaginal estrogen, take a pea-sized amount, put it down in the vagina twice a week. And then, you'd be surprised that that intervention alone definitely helps decrease the frequency. Sometimes it's a bit of trial and error. So I'll start them on vaginal estrogen first, and then after we might add cranberry pills, even though there's... conclusive. Personally in my practice, I've found that people get good results, because you'll see a lot of patients like, yeah, I'm drinking a bunch of cranberry juice. I'm like, yeah, all that added sugar, I don't think it's worth it. Why don't you just take a cranberry pill, which is the equivalent of 10 glasses of cranberry juice?

Liz Rohr:
Totally.

Joseph Acquaye:
And then, sometimes they get started on other agents, like D-mannose, for example, or sometimes, in rare cases, I'll put them on low dose prophylactic antibiotics. But of course, I'm not a huge fan of that because of the risk of resistance. And then sometimes, you have further workup, especially let's say we've done all this stuff, and we're still having these recurrence infections. We'll do some upper tract imaging. Sometimes we'll do a cystoscopy, and then rare cases, we can find a clear etiology. But yeah, I'd say definitely in post-menopausal cis female patients, definitely vaginal estrogen is no harm, even if they have a history or breast cancer or something.

It's a very local thing, so it's not going to cause systemic side effects. I know sometimes people get scared of that, and I have patients who had estrogen receptor positive breast cancer, and they're still on vaginal estrogen. And if you look at the statistics, there's not really a correlation there. It's safe to use. You just counsel the patient about that. But otherwise, yeah, it's simple. It's easy, twice a week, pea-sized amount, and patients are usually pretty adherent to it. And then cranberry pills are available over the counter. So it's like, yeah, it's easy. You can add that, and usually kind of a multimodal approach kind of helps get the infections under control.

Liz Rohr:
Totally. And I guess from my understanding of the primary care part of recurrent UTIs, this is in that episode, it's kind of as a recap, but we want to document that it's actually an infection, it's not dysuria of another cause, and then we want to think about if it's two or more in six months or three or more in a year. Would you agree with that? It's appropriate? Okay. And then the other piece is there's lifestyle interventions. I guess I talked about this in the thing, but basically, as you already referenced, cranberry juice is not that effective.

This is my understanding, so correct me where I'm wrong. But cranberry juice is plus or minus. It's kind of anecdotal. Wiping front to back, also anecdotal. Intercourse frequency as well as spermicide, those are kind of evidence-based potential causes, but intercourse frequency, whatever. We're not necessarily going to intervene on that unless it's really uncomfortable for the patient, and then spermicide use. But in terms of other things, before we get to the referral place, or before we get to... Where do we go from there, in terms of the imaging really doesn't happen until we've tried to intervene for a while? We don't have to do imaging right away. What is your threshold for imaging?

Joseph Acquaye:
Based on their history as well. So if they say, yeah, I've had a kidney stone every year, blah blah blah, I'm like, okay, maybe I'll just image. I'm not going to wait. But if you're kind of taking the history, and there's nothing really that comes up as a red flag, then I wouldn't image right away or anything like that. You kind of focus on bowel habits. Once again, those are important, and keeping a regular bowel moments, just because you sequester a bunch of stool in the rectum, and of course it's going to be easier for it to make it to migrate. So that's always an important thing, and then hydration in general, that's always a huge thing too. But honestly, if there's no red flags that come up, and you've kind of done basic history and physical, and you've intervened where you can in terms of behavioral stuff, I think you just send them over, and then we can have that... discussion.

But to your point, make sure it's actually recurrent UTIs, because there's so much patients who come in like, yeah, I've had 12 UTIs in a year or the last six months, and then we go and look, and there's not a single positive culture.

Liz Rohr:
100%.

Joseph Acquaye:
Culture-proven UTIs, because otherwise, it's persistent dysuria. Maybe now you're treading water into interstitial cystitis, or something along those lines. So if that's the case, yeah, you can still send them over, but just make sure that patient is aware of the fact that, yeah, you didn't have a UTI every time maybe something was... not one culture I can find that was actually positive. They just kept getting treated empirically, and then they get sent.

Liz Rohr:
Totally. Yeah, I was going to say, because in real life, two to three infections in a year, two in six months, three in a year, most patients who come in with recurrent UTIs are at that place of 12, and you're like, okay. So I guess one pearl to take away, especially for newer clinicians, is... Because the IDSA guidelines, at least before, were that you could treat them empirically without the culture if you had the evidence. And then the next place is to get the culture, but yeah, culture, please. Please add a culture.

Joseph Acquaye:
It gets complicated, especially if they're just always uncomfortable or always... Because it's like, I don't know kind of what to do with this person, because I can't treat them, and they're always saying that they have some kind of baseline symptoms. It may be something deeper, maybe like an interstitial cystitis, or they may need further work up. So those ones, kind of reasonable, even though it's like, okay, well, here we go. But yeah.

Liz Rohr:
Can I sneak in a question? So I won't keep you for too much longer, but I'll sneak in a question about interstitial... You know what I'm trying to say, interstitial cystitis.

So just my understanding of interstitial cystitis is it's almost like a diagnosis of exclusion, and it's considered a general bladder irritation, pain, dysuria, from not other causes that we can understand. My understanding, at least, we're trying to reduce all those things that you were talking about of all the bladder irritants, the dark chocolate, and the seltzers, and stuff like that. But do you have any other guidance? It doesn't come up that often for me in primary care, but I've seen it enough where patients are just really uncomfortable. And I've even seen patients where they're on pain medication for it. They're on opiate pain medication for it. So I don't know. What is your experience with interstitial cystitis, or if you have any guidance for us in primary care?

Joseph Acquaye:
It's the toughest thing to treat, in my opinion, because it's hard. There's all sorts of things. Some people do benzodiazepine suppositories, or opioid suppositories, or all types of... People have done silver nitrate treatments in the past and things like that. There's not really too much, because the thing is, yeah, you can avoid the bladder irritants and do all that, and a lot of patients, they find kind of happy medium. I have some patients on things like D-mannose or Uribel, and they seem that it works for them.

But there are other patients, more invasive management, and a lot of times, they can get what's called an IC cocktail injection. So we have a cocktail, different... They vary, but basically it's a couple of different things including lidocaine, and agents that are injected into the bladder at regular intervals. And sometimes that's what patients need to control the symptoms. Definitely, in residency, I saw it much more, and I think that's definitely the way to go for these patients. There were treatments where they put some of the stuff in the bladder, and shake it up, and let that come out. Those don't really work. There's where they'd hydro-distend the bladder.

So it's basically IC cocktail injections, and a lot of times, urogynecologists will do those types of treatments. But those are tough to treat, and all you can do as a primary care provider is at least get them to avoid the irritants and see where they're at. But if they're just refractory, just send them over and then we kind of take over in terms of figuring out what's the next step. But that's challenging. I still send those patients out from time to time to... more dedicated. And I also refer those patients. It sounds funny, but there's a big IC community on TikTok. And I've learned tons of stuff about IC, applied that, and the patients have benefited from it. So it's one of those conditions that's chronic, and it's multimodal. It's not just a particular medication, or having that support system, and talking about different ideas and different ways of managing it.

Liz Rohr:
Totally. Medical TikTok is wild. Patients coming in with all of the things. So I don't spend too much time on TikTok, but I feel like I should, based on all the things that I keep hearing patients

Joseph Acquaye:
I just use it for, that's probably the only medical indication I use it for. But that's it. It's a little wild, and some of the stuff's frustrating. But there are some. When you sift through a lot of the garbage, there are actually some really good information there.

Liz Rohr:
That's awesome. So, last two questions. What is your favorite part of being a urologist?

Joseph Acquaye:
My favorite part of being a urologist is...

Liz Rohr:
Or why do you love urology too? They could be the same.

Joseph Acquaye:
Yeah, I think urology is just like, it's just wild. You see kind of everything. So I think I like the variety of it. You might see a kidney stone, and do a stone surgery, and then the next day, you'll see a renal mass and do a nephrectomy. And the next day, you'll be doing relationship counseling with a couple who are dealing with erectile dysfunction, and the next day you might be helping fertility treatments or things like that. So it'll be by doing a vasectomy. So it's a spectrum of things, and the patients are really cool. And it's all across the spectrum, and you can do all types of procedures. And you get clinic, and you get the inpatients. And you get the outpatient, and all that. So I think I like urology for... It's definitely the place you can get away with a lot of inappropriate eggplant jokes.

Liz Rohr:
Love it. It seems like a really fun place, I feel like. Yeah, I just feel like every social media person, medical social media person that is the most fun is a urologist. You know what I mean?

Joseph Acquaye:
Yeah, I'd argue that's the same. It's a very self-selecting specialty.

Liz Rohr:
And I didn't know. I had no idea that renal is more my forte in terms of my natural gravitation, but I also just maybe haven't had the experience of urology. Maybe that would be my thing.

Joseph Acquaye:
... urology.

Liz Rohr:
Sounds so fun. So I'm going to stop myself from sneaking more questions, so we can honor your time. But my last question is, where can people follow you online? Would you like people to follow you online, I guess I should ask?

Joseph Acquaye:
Yeah, feel free. The number one place, I guess I'm most active with the Instagram, and you could definitely post my handle in the copy links to Jacademic_MD on Instagram. And it's basically a lot of my nonsense with occasional medical information slipped in there. But I think it gives me a chance to kind of interface with people, and I like to actually get some educational stuff in there from time to time. But that's probably the main place. And then I am on TikTok, which is slowly burgeoning. My TikTok is actually dikdok_md. So place the T with a D, and underscore-MD.

Liz Rohr:
I love it. You have one of my favorite social media accounts, for real, for real, for real. I love it so much. You're so funny. Thank you so much for being here. This is amazing, and I hope you have a wonderful weekend. But yeah, actually, I didn't ask. Any other parting words you would like to share?

Joseph Acquaye:
No, I think it's really great to see that you have APPs, and PAs, and NPs kind of trying to bridge that gap in terms, like you said, school, clinic. And I think that it definitely makes it easier for anybody involved when you kind of know when to refer, when to try to tackle it. And I think there's no shame in saying, hey, this is too much. Let me just send it over, because that is in the best interest of the patient. And I've definitely seen patients who have suffered to their detriment over a primary care provider just not wanting to refer it. Sometimes there's the idea that, hey, there's nothing more that can be done for this. And there definitely is. It's hard to keep abreast with all the different specialties and all the new advances and things like that. So just don't hesitate, especially if patient's really frustrated and have a particular problem. It wouldn't hurt to send a consult. And yeah, sometimes we might gripe and moan, but we'll see the patient, and lot of times, yeah, okay, they actually have a legit problem. Let's take care of it.

Liz Rohr:
Totally, totally. Well, thank you so much for saying that, because I think everybody in the Real World NP community is very patient first, excellent patient care. And I think there is so much imposter syndrome though, as newer clinicians, and it's like, oh my gosh, they're going to hate me for sending this patient. And it's like, you know what? It really is about safety first, right? It's about the patient. It's about safety first. It's all good. So I appreciate you saying that.

Joseph Acquaye:
... imposters. I sometimes wonder. I'm a urologist.

Liz Rohr:
That's so true. Well, thank you so much. This is so awesome.

Joseph Acquaye:
No problem, no problem. Thanks for having me. I really appreciate it.