Urology: History Skills

1. Urology:History & Skills

3. Learning Objectives Anatomy History Other Hx components Conditions Skills: Urine Dipstick MSU Sample Urinary catheterization DRE Cystoscopy

4. Renal System

5. Standard History Format Introduction, consent, occupation PC HPC Past Medical Hx FH Social History Drug History Systems Review Summary ICE

6. Hx of PC Pain: SOCRATES Loin pain = kidney pain � causes? Ureteric pain Voiding pain or suprapubic pain

7. Hx of PC Voiding Symptoms: Before: (how would you ask these qs?) Frequency; nocturia Urgency At the toilet: Haematuria Decreased/Increased urine output � causes? Pain on passing Smell

8. Hx of PC Voiding Symptoms: After: Incomplete emptying Bladder/postate symptoms (how would you ask these?): Hesitency Poor stream Dribbling

9. Other HxPC Qs to ask� Faints, confusion, visual disturbances Renal cancer ? brain mets: Itchiness, hiccups: Renal failure Ankle swelling Testicular masses/pain Vaginal discharge FLAWS ? fever, lethargy, appetite, weight loss, sweating ? Infection or Malignancy

10. Past Medical Hx Past Hx Family Hx Drug Hx Social Hx

11. LIKELY Scenarios Pain! Haematuria Benign Prostatic Hyperplasia Renal Failure

12. Haematuria Microscopic vs. macroscopic Painful vs. painless Painful = UTI, stones Ass symptoms - malaise CCV � colour, consistency, volume

13. Haematuria- investigations Urine: dipstick (microscopy, culture, cytology) Blood: FBC (anaemia), U&Es (renal function) Radiology: KUB with IVU. U/S for tumours of renal parenchyma. If you see a mass, do CT Special tests: Cytoscopy, early morning urine samples for TB, angiography (for AV malformations)

14. BPH- background

15. BPH- Presenting Complaint Symptoms: Storage symptoms: frequency, urgency, nocturia Voiding symptoms: weak stream, hesitancy, straining, dribbling (usually no pain/dysuria) Similar symptoms in the past?

16. BPH history continued Past Medical History: Major illnesses/ops DM (polyuria/polydipsia/UTIs) STDs Family history of prostate cancer/BPH Social history: Smoking, alcohol, drugs, family, home, stairs

17. BPH- investigations U&Es Renal U/S (upper tract dilation) PSA (>10?cancer more likely.) Urine flow test (for residual volume) Voiding diary?

18. BPH- Management Tamsulosin (alpha antagonist) Finasteride (5 alpha reductase inhibitor) Catheter TURP Alpha antagonistAlpha antagonist

19. Acute renal failure- background Pre-renal renal failure: failure of kidney perfusion, usually due to hypovolaemia. In early stages there is lack of structural damage and rapid reversibility once perfusion is restored. It is important to consider replacement of the correct fluid type. If urine output doesn�t increase in response to fluid input, the patient has progressed to acute tubular necrosis. Post-renal failure: look for evidence of obstruction e.g. Enlarged bladder, palpable kidneys, large prostate, pelvic mass on vaginal examination. Renal ultrasound shows dilated ureters.Pre-renal renal failure: failure of kidney perfusion, usually due to hypovolaemia. In early stages there is lack of structural damage and rapid reversibility once perfusion is restored. It is important to consider replacement of the correct fluid type. If urine output doesn�t increase in response to fluid input, the patient has progressed to acute tubular necrosis. Post-renal failure: look for evidence of obstruction e.g. Enlarged bladder, palpable kidneys, large prostate, pelvic mass on vaginal examination. Renal ultrasound shows dilated ureters.

20. Acute renal failure- PC Duration Systemic features: Uraemia (nausea, vomiting, anorexia, weakness/fatigue) Decreased urine output Pallor, pruritis, pigmentation, bruising Rash, myalgia, arthralgia, headache �

21. Acute renal failure- PMH Vascular disease Childhood renal disease UTIs Diabetes HTN

22. Acute renal failure- things to look out for Features suggesting underlying cause e.g. Dehydrated, hypotensive? Is this renal/pre-renal or post-renal? Features of systemic disease e.g. SLE Is this renal/pre-renal or post-renal? Are the kidneys/ bladder palpable? Is this renal/pre-renal or post-renal?

23. Acute renal failure- continued Are there any features of the complications of ARF? What are the complications!? What is the volume status of the patient?

24. Acute renal failure- investigations Blood count (anaemia, ESR) Blood culture Microscopy (casts and cells) U&Es- Ca2+, phosphate, uric acid U/S Renal biopsy

25. Acute renal failure- management Fluid balance Nutrition Nursing Adjust drug doses Dialysis?

26. Urological History Cases Volunteers!

27. Case 1 EXPLORE A UROLOGICAL COMPLAINT Time: 10 minutes Mr. Brooks is an 80 year old man who has been complaining of urinary problems. He has been referred to this clinic by the GP. You have been asked by the consultant to take a focused history of this patient. Present your findings to the examiner.

28. Case 1 - Markscheme

29. Case 2 � (taken from OSCEs for Medical Student, Volume 2) EXPLORE A UROLOGICAL COMPLAINT Time: 10 minutes Mr. Jones is an 24-year old man who has been complaining of urinary problems at the A&E department. You have been asked by the consultant to take a focused history of this patient. Present your findings to the examiner.

30. Case 2 - Markscheme

31. Hand-over to ZOHA!

32. What we�re going to cover Urine dipstick: Introduction Preparation Taking a sample Reporting the result Explaining how to take an MSU Urinary Catheterisation (handouts only)

33. Urine dipstick- introduction Changes in urine before blood? Disorders of urinary tract (e.g. Infection, nephrosis) and metabolic disorders affecting urinary excretion (e.g. Diabetes mellitus) Answer: urgency, dysuriaAnswer: urgency, dysuria

34. Urinary dipstick- questions What symptoms would make you suspect urinary infection? What urinary changes would you expect in (a) infection (b) Nephrosis (c) Diabetes mellitus?

35. Advantages of urine dipstick Disposable Quick Easy to perform Non-invasive No additional lab equipment needed

36. Urine dipstick- Preparation Wash hands Check expiry date GLOVES & APRON

37. Urine dipstick- Taking a sample Inspection: colour, particulates Immerse dipstick into urine Completely immerse strip, remove immediately Start timing Hold dipstick against colour chart after time stated on container Hold horizontally to prevent chemical mixing

39. Urine dipstick- reporting the result Report colour block result that matches most closely patients result Dispose of dipstick and wash hands

40. Taking a MSU sample- Introduction You (name, role) Confirm patient details (name, age, DOB) Confirm that they need it, and consent for explaining Previous experience? Questions

41. Taking an MSU- the procedure �You will need: Container of sterile water Gauze Sterile container� �You will need to wash your penis/ vulva very carefully, then start passing urine�

42. Taking an MSU- the procedure �Stop urinating & collect urine into the container, or catch the middle of the stream & empty the rest of the bladder as usual� �Have you any questions?� �Thank you�

43. MSU- possible questions What lab tests are done on an MSU sample? If the test was positive for blood, what might this indicate?

44. Urinary catheterization Example!

45. Digital Rectal Exam Normal Bilateral benign Unilateral benign bilateral carcinoma Unilateral carcinoma

46. Cystoscopy

48. Conclusion Well done on making it so far� See you at a tutorial soon Get in touch if you have any ideas, concerns or expectations� Include your id and / hk508/ �@ic.ac.uk