Dr Anna Lawrence. Mr Simon Van Rij

Transcription

1 Mr Simon Van Rij Urologist OneSixOne Urology Auckland Dr Anna Lawrence Urologist Auckland Surgical Centre Auckland 8:30-9:25 WS #94: Management of Common Urologic Problems in General Practice 9:35-10:30 WS #106: Management of Common Urologic Problems in General Practice (Repeated)

2 MANAGEMENT OF COMMON UROLOGICAL PROBLEMS IN GENERAL PRACTICE Dr Anna Lawrence, Urologist Mr Simon Van Rij, Urologist

3 WHO ARE WE Urologist Auckland Uro-Oncologist Robotic Urologist Urologist Auckland Neuro-Urologist, Current Clinical Lead ASRU Reconstructive Urologist plastic surgeon of penis

4 WHAT WE WILL COVER PSA Scrotal lumps, bumps and how to exam Recurrent Bladder Infections Haematuria Penile problems

5 DECLARATION OF CONFLICT OF INTEREST Simon: I confirm that I do not have any conflict of interest to declare. Anna: I confirm that I do not have any conflict of interest to declare.

6 RECURRENT UTIS Defined as 3 + UTIs in 12months Dx clinically with: Dysuria Frequency Hematuria Urgency New onset incontinence

7 RECURRENT UTISENT UTIS 50% of females will experience a UTI 25% of woman with a UTI will go on to develop recurrent UTIs If the first UTI is an E.Coli = 44% chance of developing recurrent UTIs

8 RECURRENT UTISENT UTIS Bacterial reinfection: Is a recurrence with a different organism, the same organism in more than 2 weeks, or a sterile intervening culture Bacterial persistence: Involves the same bacteria not being eradicated in the urine 2 weeks after sensitivity-adjusted treatment.

9 RECURRENT UTIS Indications for early referral: Previous abdo-/perineal surgery Previous stone disease Gross hematuria after infection resolution Bacterial persistence despite appropriate ABS Previous urological trauma / surgery Immunocompromised Urease splitting bacteria proteus/ pseudomonas Pneumaturia/ feacaluria Anything that alters the urinary tract

10 RECURRENT UTIS : INVESTIGATIONS MSU: If abnormalities of urinary track known >3 UTIs a year Renal USS: Stones High post void residuals Possible Bladder ca

11 RECURRENT UTIS: MANAGEMENT BEHAVOURIAL MANAGEMENT Fluids (>1.5l) Voiding after intercourse Spermicides Avoid constipation No good research Showers Front to back Tampons

12 RECURRENT UTIS: MANAGEMENT LOW DOSE CONTINOUS ABS: Better than no Abs Revert to previous frequency once discontinued. Minimal side effects POST -COITAL ABS: Taken with two hours No difference in outcomes to long term

13 RECURRENT UTIS: MANAGEMENT SELF INITIATED: On the shelf at home 87% accuracy of infection Rule out other causes HIPREX (+Vit C) Bactoricial Acidic environment

14 RECURRENT UTIS: MANAGEMENT POST MENOPAUSAL: Consider topical or oral HRT

15 RECURRENT UTIS: MANAGEMENT CRANBERRY: Proanthocyanidins - that prevent bacteria from sticking to the bladder wall and beginning the growth process. Need at least 36 mg/g proanthocyanidins DEBATABLE EFFECT

16 RECURRENT UTIS: MANAGEMENT D-MANNOSE: Regular use significantly reduced the risk of recurrent UTI No different than in Nitrofurantoin group in recent study but higher compliance to therapy 2g/day

17 RECURRENT UTIS: MANAGEMENT UROMUNE: Sublingual immunomodulation Section 29 3/12 of x2 sublingual for? Length of protection

18 RECURRENT UTIS: TAKE HOME POINTS 3+ a year Ix: MSU Renal USS DDX: Bladder Cancer STI Bladder pain syndrome/ic Vaginitis Pelvic inflammatory disease Fungal cystitis MX: Behavioural D mannose/ Hiprex Self initiated Post coital Estrogen replacement

19 HAEMATURIA: MICRO: On microscopic analysis of urine MACRO: Gross Frank Clots bleeding Pink urine Cola urine

20 HAEMATURIA: Anticoagulation may exacerbate bleeding Haematuria should not be attributed solely to the patient being on anticoagulation Look for an underlying cause

21 HAEMATURIA: RISK FACTORS FOR UROLOGICAL DISEASE >40 YRS Exposure to Pelvic radiation Smoking: including previous hx Phenacetin Cyclophosphamide Some HIV therapies Benzenes Aromatic amines Previous urological tumours

22 MACROSCOPIC HAEMATURIA REFER!! Outside of transient causes like UTI If in Retention ED 40% renal cancers 80% bladder cancers >13% of patients will have a significant finding

23 MICROSCOPIC HAEMATURIA 3 or greater red blood cells per high powered field Malignancy rates widely vary for microhaematuria Best evidence is 3.3%

24 MICROSCOPIC HAEMATURIA: INVESTIGATIONS Red blood cell casts Dysmorphic RBC RENAL USS: Stones Masses CYTOLOGY: Adjunct with high risk patients No longer consider standard for screening or for all patients with microscopic haematuri

25 MICROSCOPIC HAEMATURIA: ONGOING CARE.

26 HAEMATURIA :TAKE HOME POINTS Confirm Urine dipstix RBC with microscopic analysis Gross haematuria warrants thorough evaluation Don t attribute haematuria to anti-coagulates Follow haematuria longitudinally- the initial diagnosis may not be the final one

27 PENILE PROBLEMS 1. FIX IN A HURRY 2. TAKE TIME

28 FRACTURE Recognise: Immediate Detumescence +/- Pain Significant bruising/ Haematuria Late Presentation: Bruising Peyronie s disease ED

29 FRACTURE REFER EMERGENCY REQUIRES EARLY INTERVENTION Surgery within 4hours

30 FRACTURE Late Complications: Erectile Dysfunction Stricture Disease Peyronie s disease All >50% without intervention

31 PARAPHIMOSIS Recognise: Hx: Tight foreskin Catheter change Cleaning

32 PARAPHIMOSIS Foreskin retracted and unable to be return to normal Painful Swelling of retracted foreskin Auto-amputation if not treated

33 PARAPHIMOSIS Management: Emergency Refer but start some treatment Local anaesthetics Sugar Ice Manual reduction

34 PARAPHIMOSIS

35 PEYRONIE S DISEASE Recognise: Scar in the Tunica causing a bend in penis Up 10% adult males Not the same as chorde Palpable plaque on examination Hx of bend

36 PEYRONIE S DISEASE Management: Reassurance If not painful, and able to have intercourse Painful and worsening bend Bend so bad cannot have intercourse

37 PEYRONIE S DISEASE Management: No oral therapies Operations: Injectables: Xiaflex

38 ERECTILE DYSFUNCTION Recognise: Discussion that is a normal part of day to day discussion 40% at 40 years 70% at 70 years

39 ERECTILE DYSFUNCTION Management: Review Stress Medications Possible neurological disorders Anxiety Past/ present substance abuse weight

40 ERECTILE DYSFUNCTION MEDICATIONS: PD5 inhibitors Take on an empty stomach No Alcohol 4 x maximal dose If fails: why Side effects try a different brand No great enough effect - rings Expectations

41 ERECTILE DYSFUNCTION INJECTABLES Bimix Trimix Alprostadil: pain Intraurethral also >80%men obtain firm erections Initiates

42 ERECTILE DYSFUNCTION

43 THANK YOU. Questions