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Urology…

Urology…. GP Registrar teaching June 2010 Roger Walker. Background Topics Case Studies Female urology/urogynae Hot topics/recent advances Questions. Infections – UTI etc Male LUTS Female LUTS/ Female urology/ Urogynae/ incontinence Stones Scrotal lumps Male infertility/Andrology/ED

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Urology…

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  1. Urology… GP Registrar teaching June 2010 Roger Walker

  2. Background • Topics • Case Studies • Female urology/urogynae • Hot topics/recent advances • Questions

  3. Infections – UTI etc • Male LUTS • Female LUTS/ Female urology/ Urogynae/ incontinence • Stones • Scrotal lumps • Male infertility/Andrology/ED • Urological emergencies

  4. Urological cancer • Prostate cancer • Bladder cancer • Renal cancer • Testicular cancer • Penile cancer

  5. Write down a question…….?

  6. Case 1 • 23 year old female • Recurrent episodes of “cystitis” • MSU’s demonstrate coliforms Haematuria and clots on one occasion • Related to s.i at times

  7. Case 1 • Management options • General advice • regular/complete voiding • fluids • avoidance of dietary/ alcohol precipitants • Cranberry juice? • Probiotics - yaccult, live yoghurts? • bowel function • avoidance of condoms, spermicidals,diaphragm

  8. Case 1 • What tests are appropriate? • Ultrasound and KUB radiograph • Cystoscopy? • Urodynamics?

  9. Case 1-variations • -ve culture? • Post menopausal? • Sterile pyuria?

  10. Recurrent uti’s • Management options • Single dose/short course antibiotics for simple infections (3/7) • Low dose prophylaxis for 3/12 (trimethoprim/ nitrofurantoin/cephalosporin) • Self start/prn therapy • Post coital antibiotics • Topical oestrogens • Urethral dilatation

  11. www.sign.ac.uk • Evidence based guidelines on: • Uti in adult women • Uti in pregnant women • Uti in adult men • Uti in catheterised patients

  12. UTI’s • Asymptomatic bacteriuria • Common in elderly and catheterised patients • Doesn’t necessarily need treatment in these groups • Requires treatment in pregnant women • Frequently present in patients with stomas

  13. Uti’s • 3 days treatment (trimethoprim/ Nitrofurantoin) as effective as longer courses • Nitrofurantoin and pH?

  14. Case 2 • 54 year old female • Frequency/urgency • Unable to get to toilet in time • Interferes with meetings at work • Dipstick/MSU negative

  15. Case 2 • Investigations • Ultrasound • Urodynamics? • Management • Fluid restriction • Avoiding caffeinated/fizzy drinks • Pelvic floor retraining • Bladder drill

  16. Case 2 (anticholinergics) • Traditional • Oxybutynin • Propiverine (Detrunorm) • Trospium (Regurin) • Tolterodine (Detrusitol)

  17. Case 2 (anticholinergics) • Newer formulations • Oxybutynin XL • Detrusitol XL • New products • Solifenacin (Vesicare) • Darifenacin (Emselex) • Transdermal Oxybutynin patches (Kentera)

  18. What about botox? • New treatment • Widely used in medicine • Potent neurotoxin • Inhibits acetyl choline release at neuromuscular junction

  19. Botox - Indications • Failure of conservative therapy • Fluid advice • Pelvic floor exercises • Bladder retraining • Failure of medical therapy • Anticholinergics • Prior to more involved therapies • Sacral neuromodulation • CLAM Ileocystoplasty

  20. Intradetrusor Botox - Mode of administration • GA or LA • Rigid or flexible cystoscope • 20-30 injections throughout bladder • Trigone spared • 200/300 IU Botox A ( different strength to Dysport 500-1000IU)

  21. Botox - Outcome • 80-96% success rate • 7-14 day onset of action • 9-12 month efficacy • Repeated up to seven times ? Fall off in efficacy (antigenicity/ immunoresistance)

  22. Botox - Side effects • 6-10% Intermittent self catheterisation rate (CISC) • Flu like symptoms/ rash • Hypoasthenia 5-8% • ?Urinary tract infection

  23. Case 3 • 60 year old female • Urinary leakage ‘many years’ • Worse since the menopause • Previous hysterectomy • Wearing pads • Preventing normal activities

  24. Case 3 O/E • Abdomen - nad • Vaginal exam • mild atrophic change • Urethral mobility • Mild ant vaginal descent • Vault/post compartment supported • Oxford contract 3/5

  25. Case 3 • Management options • Pelvic floor exercises • Pharmacotherapy? • Urodynamics (video)

  26. Normal Mictruition standing Artifacts

  27. Case 3 • Management options • Pelvic floor exercises • Pharmacotherapy? • Urodynamics (video) • Periurethral injection (macroplastique, Zuidex) • Colposuspension • Tape/ Sling procedure (TVT)

  28. NICE guidelines • Local continence service

  29. Case 4 • 68 year old man • 8 month history of LUTS (? prostatism)

  30. Case 4 • History • Examination • UandE • Blood glucose • PSA • ?role of PSA screening

  31. Treatment I • Conservative management • Alpha blockers • 5 alpha-reductase inhibitors • Combination treatment • ? anticholinergics

  32. Treatment II • BNI • TURP (standard or laser) • Open Prostatectomy • TUMT - X

  33. Hot topics • Laser…! • Prostate (Green light, Holmium) • Stone (Holmium) • Tapes/ Slings/ Bladder Botox • Keyhole surgery… • Robotic prostatectomy • Laparoscopic • PSA

  34. Questions?

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