OBESITY, UROLOGIC CONSIDERATIONS
DESCRIPTION It is estimated that 300,000 deaths a year in the United States are associated with elevated body mass index (BMI). Cardiovascular comorbidities of obesity have been well established and there is mounting evidence that obesity impacts a number of urologic diseases. Strong correlations had been shown between obesity in women and stress urinary incontinence (SUI) secondary to increased abdominal pressure. Similarly, obese males have been shown to have increased lower urinary tract symptoms (LUTS). This may be attributable to an increase in adenoma size in BPH, although there is conflicting data regarding the effect of size on symptoms.
A direct link to obesity has also been shown in urologic stone formation. Obese patients with a stone to skin length >10 cm have poorer clearance rates with extracorporeal shock wave lithotripsy (ESWL). In addition, percutaneous nephrolithotomy (PCNL) is limited to patients who are not too obese for standard sheath and nephroscope lengths.
Research has shown an increase number of malignancies in patients who are obese. This is true with some urologic cancers. Prostate cancer has been shown to be more prevalent in obese patients as is adverse pathology. Renal cell carcinoma (RCC) is also associated with obesity.
The increased incidence in prostate cancer in obese men is postulated to result, at least partially, by conversion of testosterone to estradiol in adipocytes. Likewise, this aromatization of androgens leads to decreased fertility in young males. Sexual dysfunction is observed in obese men as a result of increased rates of hypertension, diabetes, and vascular disease. (See also Section II: “Body Mass Index (BMI), Urologic Considerations.”)
REFERENCE
Mydlo JH. The impact of obesity in urology. Urol Clin N Am. 2004;31:275–287.
OBTURATOR NERVE INJURY, INTRAOPERATIVE
DESCRIPTION The obturator nerve, which provides motor innervation of medial thigh adductor muscles, can be injured in surgeries involving pelvic lymphadenectomy, such as prostatectomy and cystectomy. In addition, excessive hip flexion or cautery injury during surgery can cause neurapraxia of the obturator nerve. Postoperatively, EMG can be helpful in making the diagnosis. Symptoms include gait disturbance, pain, or anesthesia along the nerve’s sensory distributions along the inner thigh and scrotum. Thigh adduction will be impacted. The incidence of intraoperative obturator nerve injury is not well documented but thought to be rare. When transection of the obturator nerve is identified intraoperatively, surgical repair may be done by end-to-end anastomosis or grafting when achieving tension-free anastomosis is not possible. Nerve transection can be repaired with end-to-end approximation of nerve edges with four 6–0 to 10–nylon or Prolene epineural stitches, using magnification if possible. Efforts must be made to align the nerve fibers prior to approximation. An absorbable collagen implant nerve wrap/protector (NeuraWrapTM), can facilitate the repair when applied to the new anastomosis. If the nerve is frayed and grossly devitalized, efforts can be made to trim both segments sharply. In the event of a significant gap, nerve-grafting techniques can be performed at a later date using a sural nerve (which is a nonessential nerve) graft.
REFERENCE
Spaliviero M, Steinberg AP, Kaouk JH, et al. Laparo-scopic injury and repair of obturator nerve during radical prostatectomy. Urology. 2004;64(5):1030.
OBTURATOR REFLEX, UROLOGIC CONSIDERATIONS
DESCRIPTION Stimulation of the obturator nerve during surgical procedures (eg, transurethral resection of bladder tumors located on the posterolateral wall, or laparoscopic pelvic lymph node dissection) can cause unexpected adduction of the thigh. Surgeons must be aware of this response so as not to cause inadvertent injury, such as perforation of the bladder. The response can usually be prevented by muscle-paralyzing anesthetic agents.
REFERENCE
Jones JS, Campbell SC. Non-Muscle-Invasive Bladder Cancer (Ta, T1, and CIS). In: Wein AJ, Kavoussi LR, Novick AC, et al., eds. Campbell-Walsh Urology. 9th ed. Philadelphia, PA: Saunders Elsevier; 2007.
O’LEARY–SANT SCORES (O’LEARY–SANT INTERSTITIAL CYSTITIS SYMPTOM INDEX [ICSI])
DESCRIPTION The ICSI is a validated questionnaire that documents and scores patient’s urinary symptoms as well as the level those symptoms cause a problem in their life. The questionnaire can be administered without the supervision of a professional interviewer. It focuses on the symptoms of urinary urgency, frequency, nocturia, and dysuria/ pain over a 30-day period. It has been found useful as a tool to follow symptoms of but not the diagnosis of interstitial cystitis.
REFERENCE
O’Leary MP, Sant GR, Fowler FJ Jr, et. al. The interstitial cystitis symptom index and problem index. Urology. 1997;49(5A Suppl):58–63.
OLIGOASTHENOTERATOSPERMIA
DESCRIPTION Oligoasthenoteratospermia describes very generalized abnormalities in sperm concentration, motility, and morphology. The cause of these combined defects in sperm parameters are commonly caused by the effects of a varicocele (most commonly cited cause), cryptorchidism, and other transient insults such as heat, drugs, or environmental toxins. Trichomonas has been implicated in some studies. Treatment involves the removal of potentially offending spermatotoxins and a repeat semen analysis in 3 mo. No good data exist on the use of agents such as bromocriptine, clomiphene citrate, human chorionic gonadotropin (hCG), or tamoxifen. (See also Section I: “Infertility”; Section II: “Semen Analysis, Abnormal Findings and Terminology”; “Semen Analysis, Technique, and Normal Values.”)
REFERENCE
Cavallini G, Crippa A, Magli MC, et al. A study to sustain the hypothesis of the multiple genesis of oligoasthenoteratospermia in human idiopathic infertile males. Biol Reprod. 2008;79(4):667–673.
OLIGOSPERMIA
DESCRIPTION Oligospermia occurs when sperm density is <20 million/mL or with a total count of <50 million sperm. Severe oligospermia occurs if counts are <10 million/mL, and may be due to hormone deficiency. A count of <20 million/mL is associated with substantially decreased fertility rates. (See also Section I: “Infertility”; Section II: “Semen Analysis, Abnormal Findings and Terminology”; “Semen Analysis Technique, Normal Values.”)
REFERENCE
Grimes DA. Oligozoospermia, azoospermia, and other semen-analysis terminology: The need for better science. Fertil Steril. 2007;88(6):1491–1494.
OMPHALOCELE-EXSTROPHY OF THE BLADDER—IMPERFORATE ANUS-SPINA BIFIDA DEFECTS (OEIS) COMPLEX
DESCRIPTION This complex represents the most severe end of a spectrum of birth defects, the exstrophy-epispadias sequence, which, in order of increasing severity, includes phallic separation with epispadias, pubic diastasis, vesical exstrophy of the bladder and cloacal exstrophy, and OEIS complex. The incidence of the OEIS complex is rare (1 of 200,000–400,000 pregnancies). Exstrophy of the cloaca includes the persistence and exstrophy of a common cloaca that receives ureters, ileum, and a rudimentary hindgut and is associated with failure of fusion of the genital tubercles and pubic rami. Other anomalies include incomplete development of the lumbosacral vertebrae with spinal dysraphism; imperforate anus; cryptorchidism and epispadias in males; anomalies of the müllerian duct derivatives in females; and a wide range of urinary tract anomalies including renal defects. Omphalocele (a defect in the umbilical ring, through which the peritoneum and an amnion-covered sac herniate) is common, and most patients have a single umbilical artery. The etiology of the OEIS complex is still unclear; single defects in blastogenesis and mutations in homeobox genes, such as HLXB9, have been suggested as responsible. Although often fatal, extensive surgical reconstruction has been successful.
REFERENCE
Keppler-Noreuil K. Prenatal ascertainment of OEIS complex/cloacal exstrophy: 15 new cases and literature review. Am J Med Genet A. 2007;143A(18):2122–2128.
OPIOID-INDUCED HYPOGONADISM
DESCRIPTION Opioids are a considerable source of drug abuse and addiction worldwide. Chronic use of opiate medication whether under supervision or illicit causes hypogonadism by actions on opioid receptors in the hypothalamus with additional actions of elevating prolactin levels and direct suppression of the pituitary and testes. Testosterone levels have been decreased as low as 50% after a single dose of opiate. Testosterone levels recover in 24–72 hr but can be suppressed up to a month depending on dose. Hypogonadism induced by opioids can be treated with hormone replacement therapy.
REFERENCE
Reddy RG, Aung T, Karavitaki N, et al. Opioid induced hypogonadism. BMJ. 2010;341:605–606.
OPITZ–FRIAS SYNDROME
DESCRIPTION Also called the G syndrome (named for 1 of the 1st patients), this condition is due to a defect of midline development, characterized by numerous congenital abnormalities, especially of the face. Many patients have hypertelorism and posteriorly rotated ears; hypospadias is almost always present. Other manifestations include cleft lip and palate, high tracheal bifurcation, duodenal stricture, imperforate anus, lung hypoplasia, and cardiac abnormalities. Inheritance is autosomal dominant with incomplete penetrance. Carriers show minimal abnormalities. It is more common in males, and perinatal mortality is around 30%.
REFERENCE
Conlon BJ, O’Dwyer TH. The G syndrome, Opitz oculo-genital-laryngeal syndrome, Opitz BBB/G syndrome, Opitz-Frias syndrome. J Laryngol Otol. 1995;109(3):244–246.
ORAL–FACIAL–DIGITAL (OFD) SYNDROME
DESCRIPTION At least 11 different types of oral–facial–digital (OFD) syndromes have been described. OFD type I is an X-linked dominant condition characterized by malformations of the face, oral cavity, and digits with polycystic kidney disease and variable involvement of the CNS. Facial milia, orofacial defects such as cleft palate, hand deformities, including shortening of the phalanges, and CNS defects are noted. Of urologic interest, renal cystic disease is found that resembles autosomal dominant polycystic kidney disease in appearance and course. Liver and pancreatic cysts may be observed. Polycystic kidney disease occurs in fewer than 50% of individuals with OFD type 1; the exact frequency is unknown. Renal cysts can develop from both tubules and glomeruli. The age of onset is most often in adulthood, but renal cysts in children have been described. ESRD has been reported in affected girls and women ranging in age from 11–70 yr. Recently it has been emphasized that the risk for significant renal disease may be greater than previously reported. Close monitoring of renal function if renal cystic disease present and renal replacement therapy, as needed.
REFERENCE
Toprak O, Uzum A, Cirit M, et al. Oral-facial-digital syndrome type 1, Caroli’s disease and cystic renal disease. Nephrol Dialys Transplant. 2006;21(6):1705–1709.
ORCHITIS, GRANULOMATOUS
DESCRIPTION This condition encompasses a group of disorders that have similar clinical and pathologic findings. It is usually of sudden clinical onset during the 6th–7th decades of life. The patient may complain of a painful and swollen scrotum, and occasionally fever and/or skin changes may be present. Often, the diagnosis is rendered postoperatively after inguinal orchiectomy is performed for presumed malignancy and histology shows chronic inflammation with granuloma. The most common cause is Mycobacterium tuberculosis. Less commonly, brucellosis, actinomycosis, and sarcoidosis are found. The condition can be a rare complication of intravesical bacillus calmette-Guérin therapy for urothelial cancer. If TB is suspected, antitubercular chemotherapy is warranted, with operative treatment for medical failures. For other causes, medical and/or surgical therapy can be utilized.
REFERENCE
Harving SS, Asmussen L, Roosen JU, et al. Granulomatous epididymo-orchitis, a rare complication of intravesical bacillus Calmette-Guérin therapy for urothelial cancer. Scand J Urol Nephrol. 2009;24:1–3.
ORGASMIC PAIN (PAINFUL EJACULATION)
DESCRIPTION Pain associated with ejaculation and orgasm is widely underreported. The nature, duration, and location of the pain can vary widely between patients. The exact cause of the pain is unknown but can be related to previous surgery (including RP), ejaculatory duct stones, pudendal nerve neuropathy, and antidepressant medications. Treatments include the use of conservative measures, anti-inflammatory medications, α-blockers, topiramate, steroid injections, relief of seminal duct obstruction, and surgical interventions such as neurolysis and fasciotomy of Alcock canal. (See also Section I: “Ejaculatory Disturbances [Delayed, Decreased, or Absent].”)
REFERENCE
Ilie CP, Mischianu DL, Pemberton RJ. Painful ejaculation. BJU Int. 2007;99:1335–1339.
ORTHO-PHTHALALDEHYDE (OPA) CHEMICAL DISINFECTANT
DESCRIPTION OPA 0.55% is a chemical disinfectant for instruments such as cystoscopes. It can irritate eyes, skin, nose, and other tissues. OPA is FDA approved as a high-level disinfectant (12 min at 20°C and 5 min at 25°C). Anaphylactic reactions have been reported in patients with bladder cancer who underwent repeated cystoscopy with scopes sterilized with OPA. OPA is contraindicated in patients with a history of bladder cancer but can be used in manual or automated reprocessing protocols.
REFERENCE
http://www.auanet.org/education/guidelines/flexible-cystoscopes.cfm, Accessed January 25, 2014.
OSSIFYING RENAL TUMOR OF INFANCY
DESCRIPTION Rare, calcified tumor of infancy, usually resembling a renal pelvis calculus. Occurs usually in 1st year of life, with gross hematuria as the most common presenting symptom. Anatomic and histologic origins are unclear but are thought to be of urothelial origin. Lesions are apparently benign, with no reported cases of recurrence or metastasis. Surgical enucleation with renal-sparing procedure is the treatment, with careful follow-up using renal sonograms, as necessary.
REFERENCE
Hu J, Wu Y, Qi J, et al. Ossifying renal tumor of infancy (ORTI): A case report and review of the literature. J Pediatr Surg. 2013;48(2):e37–e40.
OSTEONECROSIS OF THE JAW (ONJ), UROLOGIC CONSIDERATIONS
DESCRIPTION Osteonecrosis is a newly recognized complication of long-term therapy with bone strengthening agents in patients with metastatic cancer to the bone such as prostate, breast and renal cell carcinoma and in multiple myeloma. Bisphosphonates and denosumab decrease cancer-induced bone resorption thereby reducing SREs, pain, and improving quality of life. Initially identified as bisphosphonate-induced ONJ, it now recognized as a potential complication of denosumab as well. ONJ is classified as exposed necrotic maxillofacial bones for >8 wk in patients treated with bisphosphonates or denosumab who have not had radiation to the jaws. The exposed bone becomes infected with oral flora resulting in significant pain and need for oral surgery. A new term is bisphosphonate-related osteonecrosis of the jaws (BRONJ). Symptoms include pain, swelling, redness, or other signs of infection in the gums; gums or sockets that don’t heal after dental work; loose teeth and numbness or a heavy feeling in the jaw. The risk of developing ONJ is related to the potency of the antiresorptive, the duration of exposure, and dentoalveolar trauma. Prospective studies of patients taking bisphosphonates for metastatic prostate cancer that include regular exam by dentists estimate an incidence as high as 20% which is much higher than retrospective studies that suggested an incidence of 3–6%. Dental clearance before initiating therapy is recommended as well as avoiding extensive dental work while on therapy.
REFERENCE
Walter C, Al-Nawas B, Grötz KA, et al. Prevalence and risk factors of bisphosphonate – associated osteonecrosis of the jaw in prostate cancer patients with advanced disease treated with Zoledronate. Eur Urol. 2008;54:1066–1072.
OSTEOPOROSIS AND OSTEOPENIA, UROLOGIC CONSIDERATIONS
DESCRIPTION Osteoporosis and osteopenia are conditions of decreased bone mineral density (BMD) that lead to an increased risk of fracture. Although traditional emphasis has been placed on diagnosing osteoporosis in women, as the male population ages, increased numbers of men are at risk for developing skelet al fractures. In addition, more men are being placed on long-term androgen-deprivation therapy (orchiectomy of LHRH analog) as treatment for prostate cancer, which further increases the risk for osteopenia and osteoporosis. A DEXA scan can be used prior to treatment to measure BMD. Central DEXA is the gold standard and measures the spine and hip BMD. The T-score is the number of SDs by which the patient’s bone mass falls above or below the mean peak bone mass for a 30-yr-old healthy adult. For every 1 SD decrease in T-score, relative risk of fracture increases ∼1.5–2.5-fold. According to the National Osteoporosis Foundation, a normal T-score is >–1, osteopenia is –1 to –2.5, and osteoporosis is <–2.5. Further, it is recognized that, in addition to cancer treatment–induced bone loss, many men may suffer skelet al related events (SRE’s) as a consequence of bony metastatic disease. Improving BMD may also decrease SREs (radiation for bone pain or to treat pathologic fractures or spinal cord compression, pathologic fractures, spinal cord compression, and vertebral body collapse or surgery to bone). (See also Section II: “Bone Mineral Density, Urologic Considerations.”)
TREATMENT
• Calcium: 1,200 mg/d; it is recommended most cal-cium come from foods (dairy, green leafy vegetables)
• Vitamin D: At least 800–1,000 IU/d preferable from foods (fatty fish and oils, liver, fortified milk) with sun exposure of 30 min/d or supplements
• Exercise to include weight bearing
• Stop smoking; limit alcohol and caffeine
• Consider bisphosphonates:
– Alendronate (Fosamax, Fosamax Plus D) approved for treatment of men with osteoporosis and treatment/prevention of osteoporosis in men taking glucocorticoids
– Risedronate (Actonel, Atelvia) approved for treatment of men with osteoporosis and treatment/prevention of osteoporosis in men taking glucocorticoids.
– Pamidronate (Aredia) for men with Paget disease, hypercalcemia of malignancy, malignant myeloma
– Zoledronic acid (Zometa); 4 mg/monthly IV approved for bony metastasis but not male osteoporosis
– Zoledronic acid (Reclast); 5 mg/yr IV in men with Paget disease and osteoporosis
• Consider denosumab: Injectable monoclonal antibody to RANK ligand, decreases osteoclast activity
– Prolia: Men on ADT or osteoporosis 60 mg SC Q 6 mo
– Xgeva : Men with metastasis, not men with osteoporosis: 120 mg SC Q every 4 wk.
REFERENCES
National Osteoporosis Foundation Clinician’s Guide to Prevention and Treatment of Osteoporosis. Online guidelines. Available at http://www.nof.org/hcp/practice/practice-and-clinical-guidelines/clinicians-guide, Accessed March 17, 2013.
Tombal B. Practical guide to bone health in spectrum of advanced prostate cancer. Can J Urol. 2014;21(2 Suppl 1):84–92.
OSTEOTOMY, UROLOGIC CONSIDERATIONS
DESCRIPTION Osteotomy is the surgical techn-ique of cutting bone to its shape, length, or alignment. This becomes of particular necessity in surgical repair of bladder exstrophy to correct a wide pubic diastasis. Advantages of pelvic osteotomy include decreased bladder dehiscence, improved continence, and less late pelvic organ prolapse in females.
REFERENCE
Vining NC, Song KM, Grady RW. Classic bladder exstrophy: Orthopaedic surgical considerations. J Am Acad Orthop Surg. 2011;19:518–526.
OVARIAN CANCER, UROLOGIC CONSIDERATIONS
DESCRIPTION Ovarian cancer is the leading cause of death from gynecologic cancer and is usually of epithelial origin. These tumors can often involve adjacent structures or cause extrinsic compression of the urinary tract, including the bladder and ureters, with the resultant need for urologic intervention.
REFERENCE
Coleman RL, Gershenson DM. Neoplastic diseases of the ovary: Screening, benign and malignant epithelial and germ cell neoplasms, sex-cord stromal tumors. In: Katz VL, et al., eds. Comprehensive Gynecology. 5th ed. St. Louis, MO: Mosby; 2007.
OVARIAN REMNANT SYNDROME
DESCRIPTION This condition is a rare complication of bilateral oophorectomy and occurs when remnants of ovarian cortex are inadvertently left behind. The remaining ovarian tissue becomes functional and cystic. Typically, patients present with pelvic pain that can be chronic or intermittent and a pelvic mass. Symptoms may begin weeks to 5 yr postoperatively. Ureteral obstruction has been reported. Excision of the ovarian remnant is the most widely accepted treatment method. Preoperative ovarian stimulation can help intraoperative identification of retained tissue. Surgery is associated with an 8–10% recurrence rate.
REFERENCES
Kho RM, Abrao MS. Ovarian remnant syndrome: Etiology, diagnosis, treatment and impact of endometriosis. Curr Opin Obstet Gynecol. 2012;24(4):210–214.
Magtibay PM, Magrina JF. Ovarian remnant syndrome. Clin Obstet Gynecol. 2006;49(3):526–534.
OVARIAN VEIN SYNDROME
DESCRIPTION Ureteral obstruction, usually right-sided, occurring secondary to occlusion by dilated ovarian veins. The ovarian veins lie adjacent to the ureters, and dilation of these veins, especially during pregnancy, is thought to result in ureteral obstruction. The obstruction is usually seen around the L3–L4 vertebral level. Symptoms include chronic flank pain, but colicky pain has also been found. The symptoms can also begin several days prior to menses and then regress. Diagnosis can be made by IV urogram, retrograde ureteropyelogram, and simultaneous angiography. Ureterolysis and ovarian vein resection can be performed using open or laparoscopic techniques.
REFERENCE
Sato F, Nomura T, Shin T, et al. Retroperitoneoscopic treatment of ovarian vein syndrome. J Laparoendosc Adv Surg Tech A. 2008;18(5):739–742.
OXALATE-ASSOCIATED RENAL DISEASE
DESCRIPTION Hyperoxaluria is associated with calcium oxalate nephrolithiasis. An increased oxalate production or absorption, or an idiopathic form, might be responsible for the disease. In cases of primary hyperoxaluria, stone formation usually starts during childhood, with eventual tubulointerstitial nephropathy and chronic renal failure. Oxalate deposition in heart, joints, and other tissues (oxalosis) may occur. (See Section II: “Hyperoxaluria,” for the causes of increased urinary oxylate.)
TREATMENT
• Pyridoxine supplements (200–400 mg/d) for primary hyperoxaluria
• Oral hydration; low-oxalate, low-fat diet for enteric hyperoxaluria
• Pyridoxine and thiazides for idiopathic hyperoxaluria
REFERENCES
Danpure CJ. Molecular and cell biology of primary hyperoxaluria type I. Clin Invest Med. 1994;72:725.
Scheinman JI. Primary hyperoxaluria: Therapeutic strategies for the 90s. Kidney Int. 1991;40:389–399.
OXALATE, DIETARY
DESCRIPTION An excessive intake of oxalate-rich products, should be limited or avoided to prevent an oxalate load. This includes fruits and vegetables rich in oxalate such as wheat bran. This is particularly important in patients in whom an high oxalate excretion has been demonstrated. Vitamin C is a precursor of oxalate, but its role as a risk factor in calcium oxalate stone formation remains controversial. Some studies have shown that a daily intake of up to 4 g might be allowed without risk. However, a recent study demonstrated an increased risk in stone formation for men taking 1 g/d or more of vitamin C vs. <90 mg. It therefore seems justified to advise calcium oxalate stone formers to avoid excessive intake of vitamin C. (See also Section I: “Urolithiasis, Calcium Oxalate/Phosphate.”) The following products have high oxalate content:
• Rhubarb, 530 mg oxalate/100 g
• Spinach, 570 mg oxalate/100 g
• Cocoa, 625 mg oxalate/100 g
• Tea leaves, 375–1,450 mg oxalate/100 g
• Nuts, 200–600 mg oxalate/100 g
REFERENCE
Tiselius HG, Alken P, Buck C, et al. EAU Guidelines on Urolithiasis. http://www.uroweb.org/fileadmin/user_upload/Guidelines/Urolithiasis.pdf, Accessed April 6, 2014.