mr noor buchholz consultant urological surgeon director endourology and stone services n.
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Mr. Noor Buchholz Consultant Urological Surgeon & Director Endourology and Stone Services. Urological common cases in GP practice. 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?

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mr noor buchholz consultant urological surgeon director endourology and stone services
Mr. Noor Buchholz

Consultant Urological Surgeon & Director Endourology and Stone Services

Urological common cases in GP practice

case 1

33 year old female

Dysuria, frequency, cloudy urine

No fever, no kidney pain

No Hx of similar episodes

Case 1
case 11

Wait for urine culture?

  • Imaging?
  • Refer to urology?
  • Immediate treatment?
Case 1
case 12

Wait for urine culture?

  • Imaging?
  • Refer to urology?
  • Immediate treatment?
  • Dipstick sufficient
Case 1
case 13

Wait for urine culture?

  • Imaging?
  • Refer to urology?
  • Immediate treatment?
  • Dipstick sufficient
  • Not needed
Case 1
case 14

Wait for urine culture?

  • Imaging?
  • Refer to urology?
  • Immediate treatment?
  • Dipstick sufficient
  • Not needed
  • No
Case 1
case 15

Wait for urine culture?

  • Imaging?
  • Refer to urology?
  • Immediate treatment?
  • Dipstick sufficient
  • Not needed
  • No
  • yes
Case 1
case 16

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

Case 1
case 18

Urine culture?

  • Imaging?
  • Refer to urology?
  • Immediate treatment?
Case 1
case 19

yes

  • Urine culture?
  • Imaging?
  • Refer to urology?
  • Immediate treatment?
Case 1
case 110

Yes

  • Urography, cystography, cystoscopy not routinely – perhaps US KUB
  • Urine culture?
  • Imaging?
  • Refer to urology?
  • Immediate treatment?
Case 1
case 111

Yes

  • Urography, cystography, cystoscopy not routinely – perhaps US KUB
  • Not in the abscence of risk factors
  • Urine culture?
  • Imaging?
  • Refer to urology?
  • Prophylactic treatment?
Case 1
case 112

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
case 113

Yes

  • Urography, cystography, cystoscopy not routinely – perhaps US KUB
  • Not in the absence of risk factors
  • optional
  • Urine culture?
  • Imaging?
  • Refer to urology?
  • Prophylactic treatment?
Case 1
case 114

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
case 116

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
case 117

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 ≥ 105cfu/mL

Case 1
case 118

Another urine culture?

  • Imaging?
  • Refer to urology?
  • Treatment in the abscence of symptoms?
Case 1
case 119

Another urine culture?

  • Imaging?
  • Refer to urology?
  • Treatment in the abscence of symptoms?
  • in an asymptomatic pregnant woman, bacteriuria is considered significant if two consecutive voided urine specimens grow ≥ 105cfu/mL of the same bacterial species on quantitative culture
Case 1
case 120

Another urine culture?

  • Imaging?
  • Refer to urology?
  • Treatment in the abscence of symptoms?
  • in an asymptomatic pregnant woman, bacteriuria is considered significant if two consecutive voided urine specimens grow ≥ 105cfu/mL of the same bacterial species on quantitative culture
  • US KUB to exclude hydronephrosis – avoid Xray where possible
Case 1
case 121

Another urine culture?

  • Imaging?
  • Refer to urology?
  • Treatment in the absence of symptoms?
  • in an asymptomatic pregnant woman, bacteriuria is considered significant if two consecutive voided urine specimens grow ≥ 105cfu/mL of the same bacterial species on quantitative culture
  • 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
case 122

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

G6PD = glucose-6-phosphate dehydrogenase

Case 1
slide25

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
case 21

Refer immediately to urology?

  • Further imaging?
  • Risk factors for Ca?
Case 2
case 22

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
Case 2
case 24

Further imaging

  • May loose time in case of proven microhaematuria
  • One-stop haematuria clinic
  • CT – IVU & cystoscopy
Case 2
recognized causes of microscopic hematuria

Glomerular causes

Alport's syndrome

Fabry's disease

Goodpasture's syndrome

Hemolyticuremia

Henoch-Schönleinpurpura

Immunoglobulin A nephropathy

Lupus nephritis

Membranoproliferativeglomerulonephritis

Mesangial proliferative glomerulonephritis

Nail-patella syndrome

Other postinfectiousglomerulonephritis: endocarditis, viral

Poststreptococcalglomerulonephritis

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

Recognized Causes of Microscopic Hematuria
recognized causes of microscopic hematuria1

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

Recognized Causes of Microscopic Hematuria
recognized causes of microscopic hematuria2

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

Recognized Causes of Microscopic Hematuria
case 3

33 year old female

Obese, blond

Pain right upper abdomen after food

Case 3
case 32

Imaging?

  • Questions to be asked?
  • US abdomen:
  • Gallstones
  • 2cm single simple cyst in left kidney
Case 3
case 33

Imaging?

  • Further imaging?
  • Refer urology?
  • Follow up?
  • Treatment needed?
  • US abdomen:
  • Gallstones
  • 2cm single simple cyst in left kidney
Case 3
case 34

Imaging?

  • Further imaging?
Case 3
case 35

Imaging?

  • Further imaging?
  • CT-IVU if complex cyst or symptomatic only
Case 3
case 36

Imaging?

  • Further imaging?
  • Refer urology?
  • If symptomatic and/ or complex cyst
Case 3
case 37

Imaging?

  • Further imaging?
  • Refer urology?
  • Follow up?
Case 3
case 38

Imaging?

  • Further imaging?
  • Refer urology?
  • Follow up?
  • If symptomatic and/ or complex cyst
Case 3
case 39

Imaging?

  • Further imaging?
  • Refer urology?
  • Follow up?
  • Treatment needed?
Case 3
case 310

Imaging?

  • Further imaging?
  • Refer urology?
  • Follow up?
  • Treatment needed?
  • If symptomatic and/ or complex cyst
Case 3
case 4

55 year old male

Routine check-up PSA 5.8

No LUTS

No family Hx of prostate cancer

Case 4
case 42

Further diagnostics?

  • RDE: medium-sized firm smooth prostate, non-tender, no nodules
Case 4
case 43

Further diagnostics?

  • Differential diagnosis?
  • RDE: medium sized firm amooth prostate, non-tender, no nodules
Case 4
case 44

Further diagnostics?

  • Differential diagnosis?
  • RDE: medium sized firm amooth prostate, non-tender, no nodules
  • Prostatitis (asymptomatic)
  • Mechanical (catheter etc.)
  • Prostate cancer
Case 4
case 45

Further diagnostics?

  • Differential diagnosis?
  • Refer to urology?
  • RDE: medium sized firm amooth prostate, non-tender, no nodules
  • Prostatitis (asymptomatic)
  • Mechanical (catheter etc.)
  • Prostate cancer
Case 4
case 46

Further diagnostics?

  • Differential diagnosis?
  • Refer to urology?
  • RDE: medium sized firm amooth prostate, non-tender, no nodules
  • Prostatitis (asymptomatic)
  • Mechanical (catheter etc.)
  • Prostate cancer
  • Absolutely! Patient needs TRUS-biopsy of prostate.
Case 4
case 5

18 year old male

Since 3 months painless swelling left testis

No LUTS

No other symptoms

Case 5
case 52

Examination

  • 2cm firm swelling painless adjacent to left testicle
Case 5
case 53

Examination

  • Next step?
  • 2cm firm swelling painless adjacent to left testicle
Case 5
case 54

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
case 55

US

  • TUM
  • Refer to urology?
  • 2cm epidydimal cyst
  • normal
Case 5
case 56

US

  • TUM
  • Refer to urology?
  • 2cm epidydimal cyst
  • Normal
  • Only if becomes symptomatic (pain/ discomfort/ cosmesis)
Case 5
case 6

65 year old male

Since 2 years weak stream, feeling of incomplete emptying, MF 8x day/ 3x night

Case 6
case 63

Further diagnostics?

  • RDE
  • US KUB (RU/ prostate size)
Case 6
case 64

Further diagnostics?

  • RDE
  • US KUB (RU/ prostate size)
  • PSA
Case 6
case 65

Further diagnostics?

  • Refer to urology?
  • RDE: prostate enlarged/ smooth
  • US KUB (RU/ prostate size): RU 50ml/ Pvol 45ml
  • PSA: 1.8
Case 6
case 66

Further diagnostics?

  • Refer to urology?
  • Treatment?
  • RDE: prostate enlarged/ smooth
  • US KUB (RU/ prostate size): RU 50ml/ Pvol 45ml
  • PSA: 1.8
  • No
Case 6
case 67

Further diagnostics?

  • Refer to urology?
  • Treatment?
  • RDE: prostate enlarged/ smooth
  • US KUB (RU/ prostate size): RU 50ml/ Pvol 45ml
  • PSA: 1.8
  • No
  • Alpha-blocker
Case 6
case 68

1st annual control

  • RDE: prostate enlarged/ smooth
  • US KUB (RU/ prostate size): RU 120ml/ Pvol 50ml
  • PSA: 2.1
Case 6
case 69

1st annual control

  • Refer to urology?
  • RDE: prostate enlarged/ smooth
  • US KUB (RU/ prostate size): RU 120ml/ Pvol 50ml
  • PSA: 2.1
  • Yes (symptom progression under treatment)
Case 6
case 610

1st annual control

  • Refer to urology?
  • RDE: prostate enlarged/ nodule right lobe
  • US KUB (RU/ prostate size): RU 30ml/ Pvol 35ml
  • PSA: 1.9
Case 6
case 611

1st annual control

  • Refer to urology?
  • RDE: prostate enlarged/ nodule right lobe
  • US KUB (RU/ prostate size): RU 30ml/ Pvol 35ml
  • PSA: 1.9
  • Yes (needs TRUS-biopsy)
Case 6
case 612

1st annual control

  • Refer to urology?
  • RDE: prostate enlarged/ smooth, no nodule
  • US KUB (RU/ prostate size): RU 25ml/ Pvol 40ml
  • PSA: 4.1
Case 6
case 613

1st annual control

  • Refer to urology?
  • RDE: prostate enlarged/ smooth, no nodule
  • US KUB (RU/ prostate size): RU 25ml/ Pvol 40ml
  • PSA: 4.1
  • Yes (needs TRUS-biopsy)
Case 6
case 614

Alpha-reductase inhibitor added

  • RDE: prostate enlarged/ smooth, no nodule
  • US KUB (RU/ prostate size): RU 70ml/ Pvol 55ml
  • PSA: 2.2
Case 6
case 615

Alpha-reductase inhibitor added

  • 1st annual control
  • Refer to urology?
  • RDE: prostate enlarged/ smooth, no nodule
  • US KUB (RU/ prostate size): RU 70ml/ Pvol 55ml
  • PSA: 2.2
Case 6
case 616

Alpha-reductase inhibitor added

  • 1st annual control under combination Rx
  • Refer to urology?
  • RDE: prostate enlarged/ smooth, no nodule
  • US KUB (RU/ prostate size): RU 70ml/ Pvol 55ml
  • PSA: 2.2
  • Yes (needs TRUS-biopsy)

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

Case 6