mr. noor buchholz consultant urological surgeon & director endourology and stone services

UROLOGICAL COMMON CASES IN GP PRACTICE

Mr. Noor BuchholzConsultant Urological Surgeon & Director Endourology and Stone Services

CASE 1

33 year old female Dysuria, frequency, cloudy urine No fever, no kidney pain No Hx of similar episodes

CASE 1

Wait for urine culture? Imaging? Refer to urology? Immediate treatment?

CASE 1


Dipstick sufficient

CASE 1


Dipstick sufficient Not needed

CASE 1


Dipstick sufficient Not needed No

CASE 1


Dipstick sufficient Not needed No yes

CASE 1

Antibiotics Daily dose Duration of therapy

Fosfomycin trometamol° 3 g SD 1 day

Nitrofurantoin 50 mg q6h 7 days

Nitrofurantoin macrocrystal 100 mg bid 5-7 days

Pivmecillinam* 400 mg bid 3 days

Pivmecillinam* 200 mg bid 7 days

Alternatives

Ciprofloxacin 250 mg bid 3 days

Levofloxacin 250 mg qd 3 days

Norfloxacin 400 mg bid 3 days

Ofloxacin 200 mg bid 3 days

Cefpodoxime proxetil 100 mg bid 3 days

If local resistance pattern is known (E. coli resistance < 20%)

Trimethoprim-sulphamethoxazole 160/800mg bid 3 days

Trimethoprim 200 mg bid 5 days

Table 3.1: Recommended antimicrobial therapy in acute uncomplicated cystitis in otherwise healthy premenopausal women

CASE 1

Patient has come back with cystitis x3 over 8 months

Each time ABX worked well

CASE 1

Urine culture? Imaging? Refer to urology? Immediate treatment?

CASE 1

yes Urine culture? Imaging? Refer to urology? Immediate treatment?

CASE 1

Yes Urography,

cystography, cystoscopy not routinely – perhaps US KUB

Urine culture? Imaging?

Refer to urology? Immediate treatment?

CASE 1

Yes Urography,


Not in the abscence of risk factors


Refer to urology?

Prophylactic treatment?

CASE 1

Category of risk factor Examples of risk factors

No known/associated RF - Healthy premenopausal women

RF of recurrent UTI but no risk of severe outcome - Sexual behaviour and contraceptive devices- Hormonal deficiency in post menopause- Secretory type of certain blood groups- Controlled diabetes mellitus

Extra-urogenital RF, with risk of more severe outcome

- Pregnancy- Male gender- Badly controlled diabetes mellitus- Relevant immunosuppression*- Connective tissue diseases*-Prematurity, new-born

Nephropathic disease, with risk of more severe outcome

- Relevant renal insufficiency*-Polycystic nephropathy

Urological RF, with risk or more severe outcome, which can be resolved during therapy

- Ureteral obstruction (i.e. stone, stricture)- Transient short-term urinary tract catheter- Asymptomatic Bacteriuria**- Controlled neurogenic bladder dysfunction-Urological surgery

Permanent urinary Catheter and non resolvable urological RF, with risk of more severe outcome

- Long-term urinary tract catheter treatment- Non resolvable urinary obstruction- Badly controlled neurogenic bladder

Table 2.1: Host risk factors in UTI (refer to urologist)

RF = Risk Factor; * = not well defined; ** = usually in combination with other RF (i.e. pregnancy, urological internvention).

CASE 1

Yes Urography,


Not in the absence of risk factors

optional


Refer to urology?

Prophylactic treatment?

CASE 1

Drink > 2.5 liters/ day Acidification Cranberry/

Vitamin C 1 gram/ day Genital hygiene pH-

neutral alkaline-free soaps

Empty bladder +/- sex

General advise

CASE 1

Regimens

TMP-SMX* 40/200 mg once daily

TMP-SMX 40/200 mg thrice weekly

Trimethoprim 100 mg once daily

Nitrofurantoin 50 mg once daily

Nitrofurantoin 100 mg once daily

Cefaclor 250 mg once daily

Cephalexin 125 mg once daily

Cephalexin 250 mg once daily

Norfloxacin 200 mg once daily

Ciprofloxacin 125 mg once daily

Fosfomycin 3 g every 10 days

Table 3.3: Continuous antimicrobial prophylaxis regimens for women with recurrent UTIs

CASE 1

Regimens

TMP-SMX* 40/200 mg

TMP-SMX 80/400 mg

Nitrofurantoin 50 or 100 mg

Cephalexin 250 mg

Ciprofloxacin 125 mg

Norfloxacin 200 mg

Ofloxacin 100 mg

Table 3.4: Postcoital antimicrobial prophylaxis regimens for women with recurrent UTIs

“In appropriate women with recurrent uncomplicated cystitis, self-diagnosis and self-treatment with a short-course regimen of an antimicrobial agent should be considered “

CASE 1

Behavioural and general advise as well as one-shot low-dose therapy worked well

Patient presents 2 months pregnant worried about UTI’s and baby

No acute signs of cystitis Asymptomatic bacteriuria ≥ 105 cfu/mL

CASE 1

Another urine culture? Imaging? Refer to urology? Treatment in the

abscence of symptoms?

CASE 1

Another urine culture?

Imaging? Refer to urology? Treatment in the


in an asymptomatic pregnant woman, bacteriuria is considered significant if two consecutive voided urine specimens grow ≥ 105 cfu/mL of the same bacterial species on quantitative culture

CASE 1


Imaging?

Refer to urology? Treatment in the



US KUB to exclude hydronephrosis – avoid Xray where possible

CASE 1


Imaging?

Refer to urology?

Treatment in the absence of symptoms?


US KUB

If risk factors present (pregnancy can be regarded as a risk factor!)

Asymptomatic bacteriuria detected in pregnancy should be eradicated with antimicrobial therapy

CASE 1

Antibiotics Duration of therapy Comments

Nitrofurantoin (Macrobid®) 100 mg

q12 h, 3-5 days Avoid in G6PD G6PD: glucose-6-phosphate dehydrogenasedeficiency

Amoxicillin 500 mg q8 h, 3-5 days Increasing resistance

Co-amoxicillin/clavulanate 500 mg

q12 h, 3-5 days

Cephalexin (Keflex®) 500 mg

q8 h, 3-5 days Increasing resistance

Fosfomycin 3 g Single doseTrimethoprim-sulfamethoxazole

q12 h, 3-5 days Avoid trimethoprim in first trimester/term and sulfamethoxazole in third trimester/term

Table 3.5: Treatment regimens for asymptomatic bacteriuria and cystitis in pregnancy

G6PD = glucose-6-phosphate dehydrogenase

Figure 2.1: Traditional and improved classification of UTI as proposed by the EAU European Section of Infection in Urology (ESIU)

CASE 2

45 year old male No symptoms On health check microhaematuria

CASE 2

Refer immediately to urology?

Further imaging? Risk factors for Ca?

CASE 2

Refer immediately to urology?

Dipstick haematuria is a misnomer!

false-positive by hemoglobinuria, myoglobinuria, concentrated urine, menstrual blood, rigorous exercise

Always confirm by formal MSU – then refer

http://171.66.127.177/content/75/3/227/F1.large.jpg

CASE 2

Further imaging?

CASE 2

Further imaging May loose time in case of proven microhaematuria

One-stop haematuria clinic

CT – IVU & cystoscopy

CASE 2

Risk factors for Ca?

CASE 2

Risk factors for Ca?Conclusions

The incidence of muscle-invasive disease has not changed for 5 years.

Active and passive tobacco smoking continues to be the main risk factor, while exposure-related incidence is decreasing.

The increased risk of developing bladder cancer in patients submitted to external beam radiation therapy, brachytherapy or a combination of external beam radiation therapy and brachytherapy must be taken into account during patient follow-up. As bladder cancer requires time to develop, patients treated with radiation at a young age are at the greatest risk and should be followed up closely.The estimated male-to-female ratio for bladder cancer is 3.8:1.0. Women are more likely to be diagnosed with primary muscle-invasive disease than men.

Currently, treatment decisions cannot be based on molecular markers.

RECOGNIZED CAUSES OF MICROSCOPIC HEMATURIA

Glomerular causes

Alport's syndrome Fabry's disease Goodpasture's syndrome Hemolytic uremia Henoch-Schönlein purpura Immunoglobulin A nephropathy Lupus nephritis Membranoproliferative glomerulonephritis Mesangial proliferative glomerulonephritis Nail-patella syndrome Other postinfectious glomerulonephritis: endocarditis, viral Poststreptococcal glomerulonephritis Thin basement membrane nephropathy (benign familial hematuria) Wegener's granulomatosis Nonglomerular causes Renal (tubulointerstitial) Acute tubular necrosis

Familial

Hereditary nephritis Medullary cystic disease Multicystic kidney disease Polycystic kidney disease


Infection: pyelonephritis, tuberculosis (e.g., travel to Indian subcontinent), schistosomiasis (e.g., travel to Africa) Interstitial nephritis

Drug induced: penicillins, cephalosporins, diuretics, nonsteroidal anti-inflammatory drugs, cyclophosphamide (Cytoxan), chlorpromazine (Thorazine), anticonvulsants

Infection: syphilis, toxoplasmosis, cytomegalovirus, Epstein-Barr virus

Systemic disease: sarcoidosis, lymphoma, Sjögren's syndrome

Loin pain–hematuria syndrome

Metabolic Hypercalciuria Hyperuricosuria

Renal cell carcinoma

Solitary renal cyst

Vascular disease Arteriovenous malformation Malignant hypertension Renal artery embolism/thrombosis Renal venous thrombosis Sickle cell disease


Extrarenal Benign prostatic hypertrophy Calculi Coagulopathy related Drug induced (warfarin [Coumadin], heparin) Secondary to systemic disease Congenital abnormalities Endometriosis Factitious Foreign bodies

Infection: prostate, epididymis, urethra, bladder Inflammation: drug or radiation induced Perineal irritation

Posterior ureteral valves Strictures

Transitional cell carcinoma of ureter, bladder

Trauma: catheterization, blunt trauma Tumor

Other causes

Exercise hematuria Menstrual contamination Sexual intercourse

CASE 3

33 year old female Obese, blond Pain right upper abdomen after food

CASE 3

Imaging?

CASE 3

Imaging?

Questions to be asked?

US abdomen: Gallstones 2cm single simple cyst

in left kidney

CASE 3

Imaging? Further imaging? Refer urology? Follow up? Treatment needed?

US abdomen: Gallstones 2cm single simple cyst

in left kidney

CASE 3

Imaging? Further imaging?

CASE 3

Imaging? Further imaging?

CT-IVU if complex cyst or symptomatic only

CASE 3

Imaging? Further imaging? Refer urology?

If symptomatic and/ or complex cyst

CASE 3

Imaging? Further imaging? Refer urology? Follow up?

CASE 3


Bosniak category

Features Work-up

I A simple benign cyst with a hairline-thin wall that does not contain septa, calcification, or solid components. It measures water density and does not enhance with contrast material.

Benign

II A benign cyst that may contain a few hairline-thin septa. Fine calcification may be present in the wall or septa. Uniformly high-attenuation lesions of < 3 cm, which are sharply marginated and do not enhance.

Benign

IIF These cysts might contain more hairline-thin septa. Minimal enhancement of a hairline-thin septum or wall can be seen. There may be minimal thickening of the septa or wall. The cyst may contain calcification that might be nodular and thick, but there is no contrast enhancement. There are no enhancing soft-tissue elements. This category also includes totally intrarenal, non-enhancing, high-attenuation renal lesions of > 3 cm. These lesions are generally well-marginated.

Follow-up. A small proportion are malignant.

III These lesions are indeterminate cystic masses that have thickened irregular walls or septa in which enhancement can be seen.

Surgery or follow-up. Malignant in > 50% lesions.

IV These lesions are clearly malignant cystic lesions that contain enhancing soft-tissue components.

Surgical therapy recommended. Mostly malignant tumour.

Table 4: The Bosniak classification of renal cysts

CASE 4

55 year old male Routine check-up PSA 5.8 No LUTS No family Hx of prostate cancer

CASE 4

Further diagnostics?

CASE 4

Further diagnostics? RDE: medium-sized firm smooth prostate, non-tender, no nodules

CASE 4


Differential diagnosis?

RDE: medium sized firm amooth prostate, non-tender, no nodules

CASE 4




Prostatitis (asymptomatic)

Mechanical (catheter etc.)

Prostate cancer

CASE 4



Refer to urology?




Prostate cancer

CASE 4



Refer to urology?




Prostate cancer Absolutely! Patient

needs TRUS-biopsy of prostate.

CASE 5

18 year old male Since 3 months painless swelling left

testis No LUTS No other symptoms

CASE 5

Examination

CASE 5

Examination 2cm firm swelling painless adjacent to left testicle

CASE 5

Examination

Next step?

2cm firm swelling painless adjacent to left testicle

CASE 5

Examination

Next step?

2cm firm swelling painless adjacent to left testicle

US testes/ scrotum If TU suspected TU

markers (alpha-FP, beta-HCG, LDH)

CASE 5

US

TUM

Refer to urology?

2cm epidydimal cyst

normal

CASE 5

US

TUM

Refer to urology?

2cm epidydimal cyst

Normal

Only if becomes symptomatic (pain/ discomfort/ cosmesis)

CASE 6

65 year old male Since 2 years weak stream, feeling of

incomplete emptying, MF 8x day/ 3x night

CASE 6


CASE 6

Further diagnostics? RDE

CASE 6

Further diagnostics? RDE US KUB (RU/ prostate

size)

CASE 6

Further diagnostics? RDE US KUB (RU/ prostate

size) PSA

CASE 6


Refer to urology?

RDE: prostate enlarged/ smooth

US KUB (RU/ prostate size): RU 50ml/ Pvol 45ml

PSA: 1.8

CASE 6


Refer to urology?

Treatment?



PSA: 1.8

No

CASE 6


Refer to urology?

Treatment?



PSA: 1.8

No Alpha-blocker

CASE 6

1st annual control RDE: prostate enlarged/ smooth


PSA: 2.1

CASE 6

1st annual control

Refer to urology?



PSA: 2.1

Yes (symptom progression under treatment)

CASE 6

1st annual control

Refer to urology?

RDE: prostate enlarged/ nodule right lobe


PSA: 1.9

CASE 6

1st annual control

Refer to urology?

RDE: prostate enlarged/ nodule right lobe


PSA: 1.9

Yes (needs TRUS-biopsy)

CASE 6

1st annual control

Refer to urology?

RDE: prostate enlarged/ smooth, no nodule


PSA: 4.1

CASE 6

1st annual control

Refer to urology?



PSA: 4.1 Yes (needs TRUS-

biopsy)

CASE 6

Alpha-reductase inhibitor added



PSA: 2.2

CASE 6


1st annual control

Refer to urology?



PSA: 2.2

CASE 6


1st annual control under combination Rx

Refer to urology?



PSA: 2.2

Yes (needs TRUS-biopsy)

ARI halve PSA therefore a stable PSA is effectively a doubling.

mr. noor buchholz consultant urological surgeon & director endourology and stone services

Documents