27
Urological diagnoses not to be missed
Spinal cord compression
Prostate cancer commonly metastasises to bone.
Any patient with known prostate cancer who presents with severe back pain and neurological symptoms/signs should be referred immediately. They require an emergency MRI and treatment with dexamethasone prior to urgent radiotherapy.
Renal trauma
This may be blunt or penetrating.
All penetrating injuries require immediate referral.
All children with blunt renal trauma should be referred.
In adults, a history of blunt renal trauma with microscopic haematuria may be managed conservatively, as long as they do not have haemodynamic instability.
Frank haematuria or any episode of haemodynamic instability should be referred immediately.
An urgent CT scan will assess the degree of renal injury and direct management required.
Pelvi-ureteric junction obstruction
The characteristic history of loin pain after drinking large volumes of fluid (Dietl’s crisis) is not always present.
Most commonly this diagnosis is made incidentally during investigations for other conditions or as part of antenatal ultrasound screening.
A nuclear medicine scan will determine whether a pyeloplasty or nephrectomy should be performed.
Source Diagnoses not to be missed
Haematuria and non-visible haematuria (mens health)
http://hacking-medschool.com/nvh
http://hacking-medschool.com/haematuria
Haematuria may be microscopic or macroscopic painful or painless.
unexplained haematuria warrants referral under 2WW
Investigations
MSU
Urine cytology
Kidney-ureter-bladder (KUB) ultrasound
Abdominal (KUB) radiography.
Painful macroscopic haematuria should be treated in the first instance with antibiotics while awaiting MSU results. If the MSU prove negative further investigation is required.
Heavy haematuria with clots and very painful haematuria (including clot retention) should be referred urgently to the on-call team.
Gynaecomastica
Hypertophy of the mammary gland in men – presence of a palpable disc of breast tissue at least 2 cm in diameter.
Pseudo-gynaecomastica = breast enlargement due to obesity
Causes
Cirrhosis
testicular tumour
acromegaly
throtoxiosis
Addisons
Klinefelters
Drugs
Digoxin
Spironolactone
Oestrogens
Steroids
Cimetidine
Methyldopa
Reserpine
Phenothiazides
Erectile dysfunction ED
Persistent inability to achieve and maintain a useful and satisfactory erection
Guidelines on the management of erectile dysfunction British Society for Sexual Medicine
Point and Shoot
Point Parasympathetic
Shoot Sympathetic
Medical history: including co-morbidities DM CVD depression and drugs
Sexual history: libido and spontaneous/nocturnal erections.
Physical examination: including digital rectal examination in over 50s
Investigations
Diabetes testing
Testosterone (9am), FSH and LH
Low testosterone + high FSH and LH = primary gonadal failure (treat with TRT)
Low testosterone + normal or low FSH and LH are more consistent with hypothalamic/pituitary disease (refer endocrinologist)
Drugs for ED
Phosphodiesterase type-5 inhibitors
Sildenafil tablets 25mg, 50mg, 100mg
Initially 50mg (ELDERLY 25mg) approx. 1 hour before sexual activity, subsequent doses adjusted according to response to 25-100mg as a single dose as needed; max. 1 dose in 24 hours (max. single dose 100mg).
Tadalafil tablets 10mg, 20mg
Dose: Initially 10mg approx 30 minutes-12 hours before sexual activity, subsequent doses adjusted according to response to 20mg as a single dose; max 1 dose in 24 hours.
Sildenafil and tadalafil are contraindicated in patients receiving nitrates or in patients in whom vasodilation or sexual activity are inadvisable. In the absence of information, manufacturers contraindicate these drugs in hypotension, recent stroke, unstable angina and myocardial infarction. The duration of action of sildenafil is approximately 4-5 hours; that of tadalafil is up to 24 hours. Tadalafil is an alternative to sildenafil for those patients in whom its longer duration of action may be beneficial.
Other treatments for erectile dysfunction (intraurethral and intracavernosal prostaglandins) should only be prescribed after specialist consultation.
Drug treatments for erectile dysfunction may only be prescribed on the NHS under certain circumstances
diabetes
multiple sclerosis
Parkinson’s disease
poliomyelitis
prostate cancer
severe pelvic injury
single gene neurological disease
spina bifida or spinal cord injury
dialysis for renal failure
radical pelvic surgery, prostatectomy, or kidney transplant
men receiving NHS treatment for erectile dysfunction on 14 September 1998
severe psychological distress (as assesed by specialists)
– significant disruption to normal social and occupational activities;
- marked effect on mood, behaviour, social and environmental awareness;
- marked effect on interpersonal relationships.
Prescription must be endorsed SLS.
Hypogonadism and testosterone replacement therapy
tayendoweb dundee.ac.uk hypogonadism
<a href=”http://www.medscape.org/resource/hypogonadism/cmeMedscape CME testosterone deficiency screening and work-up
Late-onset hypogonadism in men DTB 2010;48(6):69
 
Premature ejaculation
http://emedicine.medscape.com/article/435884-overview
Haematospermia
http://www.patient.co.uk/doctor/Haematospermia.htm
http://www.cks.nhs.uk/haematospermia
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1964630
Peyronies
http://kidney.niddk.nih.gov/kudiseases/pubs/peyronie
Priapism
Balanitis
Phimosis paraphimosis and foreskin problems
http://www.buf.org.uk/patient/male_phimosis.html
http://www.norm-uk.org/phimosis_clinical_guidelines.html
http://www.childrensurgery.co.uk/diagnoses/phimosis.html
http://www.malehealth.co.uk/phimosis/20298-phimosistight-foreskin
http://www.newcastle-hospitals.org.uk/services/dermatology_treatment-and-medication_balanitis.aspx
Paraphimosis
http://emedicine.medscape.com/article/442883-overview
Pearly Penile Papules
http://emedicine.medscape.com/article/1058826-overview
http://pearlypenilepapules.net/pearly-penile-papule-photos/
Fordyce Spots
http://www.fordycespots.com/fordyce-spot-photos/examples-of-fordyce-spots
http://pearlypenilepapules.com/bumps-on-penis
Lichen planus penis
http://hacking-medschool.com/lichen-planus
http://www.dermnet.com/Lichen-Planus-Penis
http://dermnetnz.org/scaly/lichen-planus.html
Penile ulcers and sores
http://www.nlm.nih.gov/medlineplus/ency/article/003221.htm
http://www.sfcityclinic.org/drk/stdtreatment10.asp
http://herpes-coldsores.com/conditions_confused_with_herpes.htm
@@@ Testicular lumps
Tumour
the testis is smooth and olive-shaped with the epididymis lying posteriorly.
Any irregular lumps palpated on the body of the testis should be referred urgently 2WW
Epididymal cysts
on palpation, these are found to be separate from the body of the testis, and with experience, examination alone is
sufficient to make the diagnosis.
They can be managed conservatively unless causing considerable pain, in which case referral for removal is indicated.
Varicocele
collection of dilated veins in the spermatic cord, which may present as chronic scrotal ache.
Opinion is divided on
whether all of these need surgery. The main risk of conservative management is a reduction in sperm count and testicular size over a
long period. Generally, it is reasonable to treat large symptomatic varicoceles in younger men.
Hydrocele
collection of fluid in the tunica vaginalis
and can be managed conservatively. They are not usually painful but
problems tend to arise as they increase in size, and at this point referral for surgery is appropriate.
Postsurgical problems
eg hernia repairs and granulomata after vasectomy.
Trauma
This is mostly blunt trauma. Provided both testes can be fully palpated and the examiner is satisfied that there is no evidence
of a ruptured testis, an outpatient ultrasound can be arranged and pain managed with simple analgesia. If the testes cannot be adequately palpated or if there is a large haematoma, then immediate referral is appropriate.
Intermittent torsion
Refer urgently for orchidopexy.
Extragenital lesions causing referred pain to the scrotum
aortic aneurysm,
urinary tract calculi,
vertebral disease
constipation
If investigations fail to yield a cause of the pain, then conservative management is employed in the first instance, ie oral analgesics, scrotal support, lifestyle changes (eg changing bicycle seats).
Nerve blocks can be both therapeutic and diagnostic but ultimately surgical exploration may be necessary
Scrotal and testicular swelling
Paeds
pediatriceducation.org/2006/05/15
Testicular self examination
Epididymo-orchitis
Hydrocoele
Collection of fluid within tunica vaginalis.
http://www.steinergraphics.com/surgical/003_09.2E.html
http://www.urologyoncall.com/going-for-surgery/Hydrocoele-Surger/step1/lang1
Varicocoele
Abnormal dilatation of pampiniform plexus of veins in the scrotum.
http://emedicine.medscape.com/article/438591-treatment
Testicular Cancer
Seminoma
Teratoma
http://www.cancerlinksusa.com/testicular/index.asp
Seminoma
http://emedicine.medscape.com/article/437966-overview
Teratoma Testis
http://emedicine.medscape.com/article/281850-overview
Cancer Penis
http://emedicine.medscape.com/article/446554-overview
http://www.cancer.gov/cancertopics/types/penile
Testicular and Scrotal Pain and Torsion
http://emedicine.medscape.com/article/778086-overview
http://urology.ufl.edu/testicularpain
Testicular Torsion
http://emedicine.medscape.com/article/778086-overview
Epididymitis
http://emedicine.medscape.com/article/436154-overview
Vasectomy
http://www.patient.co.uk/health/Vasectomy.htm
http://www.vasectomy-clinic.co.uk
Semen Analysis
http://www.umc.sunysb.edu/urology/male_infertility/SEMEN_ANALYSIS.html
http://www.fertilityformen.com/info_normal.php
http://www.netdoctor.co.uk/menshealth/facts/semenandsperm.htm
http://www.patient.co.uk/health/Semen-Analysis.htm
Prostatitis
Organisms
Coliforms, Neisseria gonorrhoeae, Chlamydia trachomatis, abacterial and others.
Screening
Send first 5-10mls of urine voided for chlamydia PCR. Urethral swab for gonorrhoea.
Treatment
Ofloxacin 400mg once daily or ciprofloxacin 500mg twice daily for four weeks.
If high risk of C.difficile use trimethoprim 200mg twice daily.
Referral
To Urology for screening, diagnosis and treatment.
UTI in males
http://emedicine.medscape.com/article/231574-overview
http://www.sh.lsuhsc.edu/fammed/OutpatientManual/UTIs.htm
Sample essential pre and post treatment
1st line Trimethoprim 200mg twice daily for fourteen days but adjust according to microbiology sensitivities.
If ineffective in a sexually active male consider referral as chlamydia is a known cause.Post-treatment sample.
Refer after first proven UTI, with or without symptoms of prostatitis.
LUTS BPH Prostatism
Benign Prostatic Hypertrophy BPH Prostatism LUTS
BAUS Primary care management of LUTS Feb 2004 doctorjohnson.co.uk
BPH drugs
Drugs used in bladder outflow obstruction – alpha-blockers
FIRST CHOICE: TAMSULOSIN
Tamsulosin m/r capsules 400 micrograms od
Doxazosin tablets 1mg, 2mg, 4mg
Dose: initially 1mg daily; dose may be doubled at intervals of 1-2 weeks according to response, up to max. 8mg daily; usual maintenance 2-4mg daily.
Alfuzosin tablets 2.5mg, m/r tablets 10mg
Dose: 2.5mg 3 times daily, max.10mg daily. Elderly, initially 2.5mg twice daily. 10mg m/r once daily.
Alpha-blockers relax smooth muscle in the prostate gland, prostate capsule and bladder neck and reduce the resistance to the flow of urine out of the bladder. This improves urine flow and bladder emptying.
First dose hypotension may occur with all three products although tamsulosin is theoretically more prostate specific.
Alpha-blockers may be combined with 5 alpha-reductase inhibitors (see below).
Drugs for benign prostatic enlargement
FIRST CHOICE: Finasteride tablets 5mg od
Review treatment after 3-6 months.
Finasteride is an inhibitor of the enzyme 5 alpha-reductase.
It may take up to one year for finasteride to have maximum effect.
Finasteride causes a reduction in prostatic size of about 20% after one year however, it must be continued indefinitely to maintain any symptomatic improvement.
Finasteride can be used in conjunction with alpha-blockers.
Cases of male breast cancer have been reported with Finasteride.
Patients should be advised to promptly report to their doctor any changes in their breast tissue such as lumps, pain or nipple discharge. See MHRA Drug Safety Update December 2009 for more information.
FDA approves Cialis to treat benign prostatic hyperplasia
IPSS
International Prostate Symptom Score
IPSS www.usrf.org
| International prostate symptom score (IPSS) | ||
|---|---|---|
| Incomplete emptying | Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? | |
| Frequency | Over the past month, how often have you had to urinate again less than two hours after you finished urinating? | |
| Intermittency | Over the past month, how often have you found you stopped and started again several times when you urinated? | |
| Urgency | Over the last month, how difficult have you found it to postpone urination? | |
| Weak stream | Over the past month, how often have you had a weak urinary stream? | |
| Straining | Over the past month, how often have you had to push or strain to begin urination? | |
| Nocturia | Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? | |
| Scores | (scores) Not at all 0 Less than 1 time in 1 Less tham half time 2 About half the time 3 More than half the time 4 Almost always 5 |
(for nocturia) None 0 1 time 1 2 times 2 3 times 3 4 times 4 5 times or more 5 |
| Total Score | 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic | |
| Quality of life | If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? | |
| Score | Delighted 0 Pleased 1 Mostly satisfied 2 Mixed 3 Mostly dissatisfied 4 Unhappy 5 Terrible 6 | |
Prostate screening (urology)
http://hacking-medschool.com/prostate-screening
http://hacking-medschool.com/psa
NICE CG58 Prostate cancer Feb 2008
http://www.cancerscreening.nhs.uk/prostate/index.html
http://www.prostatecancer.ca/Prostate-Cancer/PC-Assessment-Tools
| Age | PSA (ng/l) |
|---|---|
| 40-49 | <2.5 |
| 50-59 | <3.5 |
| 60-69 | <4.5 |
| 70-79 | <6.5 |
The patient needs to be told the following:
prostate cancer is but one of several causes of a raised PSA (non-specific test)
all patients with a significantly raised PSA should have a prostate biopsy
1 in 5 men with a normal PSA will have prostate cancer
2 in 3 men with a raised PSA will not have cancer
there is no conclusive evidence that detection of early prostate cancer leads to longer survival
the test cannot distinguish between aggressive and slow-growing cancers, and may detect tumours that would not otherwise become evident in the patient’slifetime
The test is of most value in patients who are ‘high risk’ ie those > 70 years, AfroCaribbeans, and those with a family history.
At the time of the test, the patient should not have:
a UTI
ejaculated within 48 hours
a per rectum examination within 1 week
a prostate biopsy within 6 weeks
Causes of raised PSA
acute urinary retention
catheterisation
BPH/TURP
old age
prostatitis
prostate carcinoma
Benign prostatic enlargement – smooth surface: sulcus palpable
Malignant enlargement – irregular, craggy border; loss of median sulcus.
Bladder Cancer
http://emedicine.medscape.com/article/438262-overview
Bladder papillomata
http://www.nature.com/modpathol/journal/v16/n7/full/3880815a.html
http://emedicine.medscape.com/article/1627756-overview
Bladder Stones
http://emedicine.medscape.com/article/440657-overview
Urethral stricture
TUNIC
Trauma – surgery injury foreign body
Urethral valves
Neoplastic
Inflammation
Congenital eg pinhole meatus
@@@ Long term catheters
UTI in Catheterised Patient
In the presence of a catheter, antibiotics will not eradicate bacteriuria. If systemically unwell, i.e. if new costovertebral tenderness or rigors or new onset delerium or fever >37.9°C twice in 12 hours send sample, treat as below and change catheter during course.
1st line Co-amoxiclav 625mg three times daily for fourteen days or Cotrimoxazole 960mg twice daily for fourteen days.
Treatment failure / 2nd line Await result of the sensitivity report.
Tayside Guidelines for suspected UTI in elderly
Long-term catheters are most commonly used in two groups of patients:
1 The elderly with incontinence, bladder outflow obstruction or bladder failure
2 Patients with spinal injuries or other neurological conditions that affect bladder function.
Common problems with long-term urinary catheters include:
Discomfort/pain
Spasm
Bypassing
Blockage
Discharge
Urinary tract infection.
One of these problems may occur in isolation or there may be several
problems that co-exist.
Discomfort/pain can be caused by bladder spasm, catheter blockage
or infection. Treatment for spasm includes anticholinergics, reducing
the volume of the balloon and avoiding caffeinated drinks.
Blocked catheters should generally be replaced rather than flushed,
and the underlying cause of the blockage addressed. This can usually
be achieved by increasing fluid intake to at least 2 I/day and treating
any underlying infection. Cranberry juice is particularly useful as it
increases fluid intake and also has antibacterial properties. However,
it should not be used in patients on warfarin. Bladder washouts can
be helpful in those who cannot drink enough; they can help to
reduce encrustation and recurrent blockage. Saline washouts are
commonly used, or more specialised acidic solutions if the urine is
alkaline (eg mandelic acid for Proteus and Pseudomonas infections).
High oral doses of vitamin C will also acidify the urine and help
prevent encrustation. A larger-diameter catheter can also help to
reduce recurrent blockage but may cause increased pain and
discharge.
Catheter blockage can also be caused by kinking of the catheter
itself, constipation and bladder spasms.
Discharge from the urethra is common. In the uncatheterised urethra,
paraurethral gland secretions are washed out with micturition.
Catheters prevent this from happening and so the secretions present
as -a discharge around the edge of the catheter; this is normal. If the
paraurethral glands become blocked, urethritis can occur, which is
associated with a more profuse, often offensive-smelling, discharge.
Problems with this can be reduced by using a smaller diameter
catheter, ie 12 F. Smaller catheters are also more comfortable and
can help to reduce pain and spasm.
Urinary infection is commonly diagnosed, but rarely needs treatment;
asymptomatic bacteriuria is considered normal in catheterised patients.
However, signs of sepsis should be treated with antibiotics and the catheter
replaced to remove the existing biofilm.
Most long-term catheters can last up to 3 months. However, they may require
changing more frequently and this varies from patient to patient.
LONG-TERM URETHRAL CATHETERS
Long-term catheters are most commonly used in two groups of patients:
1The elderly with incontinence, bladder outflow obstruction or bladder failure
2 Patients with spinal injuries or other neurological conditions that affect bladder function.
Common problems with long-term urinary catheters include:
Discomfort/pain
Spasm
Bypassing
Blockage
Discharge
Urinary tract infection.
One of these problems may occur in isolation or there may be several
problems that co-exist.
Discomfort/pain can be caused by bladder spasm, catheter blockage
or infection. Treatment for spasm includes anticholinergics, reducing
the volume of the balloon and avoiding caffeinated drinks.
Blocked catheters should generally be replaced rather than flushed,
and the underlying cause of the blockage addressed. This can usually
be achieved by increasing fluid intake to at least 2 I/day and treating
any underlying infection. Cranberry juice is particularly useful as it
increases fluid intake and also has antibacterial properties. However,
it should not be used in patients on warfarin. Bladder washouts can
be helpful in those who cannot drink enough; they can help to
reduce encrustation and recurrent blockage. Saline washouts are
commonly used, or more specialised acidic solutions if the urine is
alkaline (eg mandelic acid for Proteus and Pseudomonas infections).
High oral doses of vitamin C will also acidify the urine and help
prevent encrustation. A larger-diameter catheter can also help to
reduce recurrent blockage but may cause increased pain and
discharge.
Catheter blockage can also be caused by kinking of the catheter
itself, constipation and bladder spasms.
Discharge from the urethra is common. In the uncatheterised urethra,
paraurethral gland secretions are washed out with micturition.
Catheters prevent this from happening and so the secretions present
as -a discharge around the edge of the catheter; this is normal. If the
paraurethral glands become blocked, urethritis can occur, which is
associated with a more profuse, often offensive-smelling, discharge.
Problems with this can be reduced by using a smaller diameter
catheter, ie 12 F. Smaller catheters are also more comfortable and
can help to reduce pain and spasm.
Urinary infection is commonly diagnosed, but rarely needs treatment;
asymptomatic bacteriuria is considered normal in catheterised patients.
However, signs of sepsis should be treated with antibiotics and the catheter
replaced to remove the existing biofilm.
Most long-term catheters can last up to 3 months. However, they may require
changing more frequently and this varies from patient to patient.