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Instant wisdom - urology

Mr Ian Eardley shares his advice on managing urological conditions in primary care

Five quick tips

1. Beware of a leaking abdominal aortic aneurysm in an older patient with apparent left-sided ureteric colic

Sudden onset loin pain is commonly caused by urological pathology such as ureteric colic or UTI. In women, ovarian pathology is another cause, as is musculoskeletal pain. A less common but very significant cause is a leaking abdominal aortic aneurysm, which can present with loin pain that is most commonly left sided. So, especially if the patient is older and has signs of blood loss, a leaking abdominal aortic aneurysm is a diagnosis to consider.

2. Persistent red patches on the glans penis or the prepuce need biopsy

Red skin lesions on the penis are reasonably common, with potential causes ranging from fungal infections to carcinoma in situ. The difficulty is in identifying which ones are potentially dangerous. Most inflammatory causes such as a fungal infection will tend to ‘come and go’, often in response to treatment. Persistent rashes can represent carcinoma in situ and are best diagnosed by biopsy, which can be performed under local anaesthetic. Persistence is the single most important feature to look for.

3. Beware of recurrent urinary infections in the elderly

Recurrent UTIs (i.e. three or more per year) are a common clinical problem, especially in women and they are often associated with bleeding. It is important to remember that they can be the presenting feature of bladder cancer – even when there is no haematuria, which might otherwise suggest an underlying problem. So, especially in older men and women, new onset recurrent UTIs should be referred for investigation by cystoscopy and imaging of the upper urinary tract (usually by ultrasound or CT scan).

4. Sudden onset of bed-wetting in an older man suggests chronic urinary retention, often with renal impairment

In these men, the bladder is almost always palpable and abdominal examination will detect this. In a more obese man, an ultrasound will identify the enlarged bladder and the hydronephrosis that often accompanies it. Chronic retention of urine in elderly men is usually due to benign prostatic hyperplasia, which causes progressive build-up of urine within the bladder with overflow incontinence, usually at night, which, often, is not associated with a sensation of bladder fullness. It typically develops gradually over several months and can lead to renal impairment. This problem needs urgent urological referral for catheterisation. When renal function is optimised, the definitive treatment is usually transurethral prostatectomy.

5. Ureteric colic with coexistent fever is a surgical emergency

In a patient who appears to have ureteric colic or who has a known ureteric calculus, the development of fever is potentially serious. It may represent infection within the obstructed system, which can result in pyonephrosis and systemic sepsis, and potentially can be fatal. The patient is often tender in the affected loin. Such cases need urgent referral to hospital where the optimal treatment involves intravenous antibiotics and percutaneous nephrostomy.

Obscure or overlooked diagnoses

1. Balanitis xerotica obliterans (BXO), also known as lichen sclerosus

BXO is a white, fibrotic lesion affecting the skin of the prepuce that causes phimosis. It also affects the glans penis in around 10% of sufferers and the anterior urethra in around 1%. It can affect boys and adults of all ages and may require circumcision, which is usually curative for preputial BXO. Strong topical steroids are often helpful, especially for disease affecting the glans penis. It is a lesion that increases the risk of the man subsequently developing penile cancer.

2. Bladder neck obstruction

The most common cause of lower urinary tract symptoms (LUTS) in older men is enlargement of the prostate, usually due to benign prostatic hyperplasia. This typically occurs in men over 50 years of age and is characterised by hesitancy, poor urinary stream, frequency of micturition and nocturia. However, a similar set of symptoms can occur in younger men, perhaps as young as 25 years of age. Here, the ‘obstruction’ is a malfunctioning bladder neck, which does not relax fully during micturition and leads to identical urinary symptoms, which may be worse when the man wishes to pass urine ‘in public’, such as in a public toilet. Treatment is with an alpha-blocker, although a proportion of men will require surgical incision of the bladder neck.

3. Urinary schistosomiasis

Painless haematuria in patients who have recently travelled to places such as Egypt or central Africa should raise the possibility of urinary schistosomiasis. This is a parasitic disease contracted when swimming or bathing in infected water where infected freshwater snails release the tapeworm, which penetrates the patient’s skin and causes the infection that most commonly presents with painless haematuria. The condition is diagnosed by identifying schistosomal eggs within the patient’s urine and can be treated effectively with oral praziquantel. Left untreated, it can cause significant scarring and fibrosis of the urinary tract and may ultimately result in bladder cancer.

Easily Confused

1. Testicular torsion and epididymitis

Testicular torsionEpididymitis

Sudden onset testicular pain

Onset of pain usually gradual

Typically affects children, adolescents and young men

Can affect any age, though rare in children. Usually caused by an STI in young men and by a UTI in older men

Testis lies higher, scrotal skin is often erythematous, spermatic cord is thickened and whole hemi-scrotum is exquisitely tender

Scrotal skin is often erythematous and oedematous, epididymis is thickened and tender and there may be a fever. In severe cases, whole hemi-scrotum is exquisitely tender

Urinalysis is negative

Urinalysis often shows pyuria

Ultrasound usually shows no testicular blood flow

Ultrasound shows hyperaemia of epididymis and possibly testis, sometimes with abscess formation

Note: Differentiating between the two is difficult. If there is any doubt, urgent referral is required because the only truly diagnostic test is surgical exploration – and testes that have torted for more than six hours are at risk of ischaemic necrosis.

2. Overactive bladder and painful bladder syndrome

Overactive bladderPainful bladder syndrome

Usual symptoms are frequency, urgency, nocturia and, commonly, urge incontinence

Usual symptoms are frequency, urgency and nocturia. Incontinence is rare

Pain is not a feature

Pain is a central component of this problem, most prominent when the bladder is full. Many women also suffer from dyspareunia

The urgency comprises a painless strong desire to void

The urgency is associated with a strong painful need to pass urine

Urinalysis typically shows no abnormality

Urinalysis is usually positive for leucocytes, and often positive for blood

Anticholinergics such as oxybutynin and beta-3 agonists such as mirabegron are the most appropriate first-line therapy

Referral for urological assessment and cystoscopy is appropriate

3. Cystitis in male and acute prostatitis

Cystitis in male  Acute prostatitis

Typical symptoms of cystitis, i.e., urgency, frequency and dysuria, possibly with visible haematuria

Typical symptoms of cystitis

Rarely difficulty passing urine

Difficulty passing urine is common

No fever

Fever

Requires a oneweek course of antibiotics

Requires a one month course of antibiotics

(e.g. ciprofloxacin)

 

Not unwell enough to warrant admission

May be unwell enough to warrant admission

Prescribing points

1. Nitrates and PDe5 inhibitors

Patients using PDE5 inhibitors such as sildenafil (Viagra) or tadalafil (Cialis) should not use nitrate medication such as GTN because of the risk of significant postural hypotension. This contraindication also applies to nicorandil and the recreational drugs ‘poppers’, which are also nitric oxide donors and can cause the same side effects.

2. 5 Alpha reductase inhibitors and PSA results

Drugs such as finasteride or dutasteride, commonly used for the treatment of male LUTS due to benign prostatic hyperplasia, have the effect of reducing PSA levels by around 50%. This is important in the follow-up of men with a raised PSA, in whom a rough adjustment of doubling the measured PSA will give the true PSA level. Alpha-blockers, which are also used in this condition, do not have this effect on PSA.

3. Antihypertensives and erectile function

While hypertension is a common cause of erectile dysfunction and most antihypertensives make the erectile dysfunction worse, the angiotensin receptor blockers actually improve erectile function. They are therefore the best class of drugs to use in men with hypertension who have coexistent erectile dysfunction.

Mr Ian Eardley is a consultant urologist at the Leeds Teaching Hospital Trust

This is an abridged version of a chapter in Instant Wisdom, a guide for GPs distilling years of knowledge, experience and key evidence into 25 easy-to-read chapters, each one covering a different specialty. Pulse is offering an exclusive 15% discount to GPs on the recommended retail price. To take advantage of this offer, click here  and enter PUL15 at the checkout.

9781138196209

 

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