Urology Case Study Workbook - Questions

Transcription

1 Urology Case Study Workbook - Questions Developed in Partnership with the CME tutors for the CME Network Facilitated by an educational grant by GlaxoSmithKline Date of Preparation. September 5th 2011 IE/DUTT/0025/11

2 Foreword Working as a urologist across both St. James s & Tallaght Hospitals for 22 years I have garnered unique insights not only into the treatment pathways for patients with urinary problems but also into the comfortable level of general practitioners in managing these conditions in the community. I believe that as secondary care physicians it is our role to support GPs, as best we can, to the appropriate management of urology conditions. One of the most effective educational tools, in my experience, is learning by case study discussion. I was therefore very keen to be involved with the CME Network in the development of the enclosed Urology Case Study Workbook and I want to pay tribute to the other contributors who are acknowledged on the following pages. I sincerely hope this workbook proves to be a useful learning and reference tool and I wish you every success in your practices. Best wishes, Mr. Ronald Grainger. MB FRCSI D.CH Consultant Urologist at Adelaide Meath Hospital Tallaght and St. James s Hospital Dublin 8. President Irish Society of Urology

3 Acknowledgements Authors of the individual Case Studies: Urinary Tract infection Mr. Ivor Cullen Male Urinary Tract Symptoms Mr. Ronan Long Haematuria Scrotal Swellings (1 & 2) Female Incontinence Mr. Arun Thomas Mr. Ron Grainger Mr. Ron Grainger Special thanks to Dr. Annraoi Finnegan, Direcrtor of CME and Dr. Illona Duffy, CME tutor & GP for their support in reviewing these case studies. Copyright Notification: Copyright belongs to the individual author of each case study. Therefore no case study can be altered or taken out of context without the expressed, written consent of the individual author. Case Study 1: Urinary Tract Infection A 33 year old lady attends your practice with a 2 day history of increased frequency of micturition, dysuria and low back pain. She has noticed a foul smell from her urine. Of note is her third attendance at your office with similar symptoms in the past 6 months. Q. How do you proceed? Q. How do you instruct your patient to collect an MSU? Q. What organisms are likely to be implicated in a community acquired UTI?

4 Q. How should you treat your patient at presentation in your surgery? Q. What advice might you give to your patient for the future? Q. When should you refer for further assessment by a Specialist? Summary notes

5 Case Study 2: Male Urinary Tract Symptoms A 61year old male presents with difficulty with urination over the previous 6 months. He is particularly bothered as he has to pass urine twice per night and also complains of hesitancy, slow stream and post micturition dribbling. He has no previous urological history or neurological symptoms. Q. How can you assess the severity of his symptoms objectively? Q. What is the most common condition in ageing men presenting with LUTS and what are the typical symptoms. Q. What other symptoms may be present secondary to obstruction. Q. What is the significance of recent onset of nocturnal enuresis in an individual with LUTs? Q. Is it necessary for a GP to do a rectal examination Q. Would you routinely send blood for PSA testing: Q. How would you advise this patient given that his DRE and PSA are normal.

6 Q. Would you commence treatment for this man? Q. Which treatment for which patient. Q. When should a patient with BPE be referred to a Urologist? Case Study 3: Haematuria A 56 year old man presents to your surgery with new onset lower urinary tract symptoms (LUTS) over the past month. He has noticed increased frequency of micturition at 2 hourly intervals and nocturia two occasions each night. He reports a good flow with no other symptoms suggestive of obstruction. He has not had any visible haematuria but has noticed that his urine has been dark in colour on occasion. Q. What may be important in his past history and why? Q. He gives a history of a 15 year pack history of smoking which he stopped 7 years ago. Physical examination including rectal examination, blood pressure etc is normal. What investigations would you order for this man?.

7 Q. One week later he returns for the results of his tests which show Hb 11.8 wcc 7.4 Urine microscopy shows red cells with no white cells and no growth. What do you do now? Q. What terminology are you aware of for haematuria? Q. What is significant haematuria? Q. When should referral to urologist be sought? Case Studies 4 to 6: Scrotal Swellings Case Study 4: A 22 year old man comes to see you with a 2 month history of left testicular pain and swelling. On examination: The left testis is normal. There is a 2 cm swelling just above the testis. Q. When presented with a scrotal swelling what is the first thing you must confirm? Q. What may help you confirm the diagnosis.

8 The swelling does transilluminate and appears cystic. Q. What is the likely diagnosis? Q. How might you manage this? Q. If the pain did not settle how would you manage it? Q. If the patient enquired if this was a malignant or pre malignant condition how would you answer? Q. If you are concerned that this is a testis tumour what should your management be? Q. What would lead you more to a diagnosis of epididymitis rather than tumour?

9 Q. What is the treatment for acute epididymitis? Q. Which would be the most appropriate antibiotic? Q. If the symptoms did not settle over a 72 hour period what other antibiotic might you employ and why?... Case Study 5: A 22 year old man presents with a similar history. On examination there is diffuse swelling in the left hemiscrotum. Q. How would you go about making a diagnosis? Q. If you are certain this is a cystic swelling what is the likely diagnosis? Q If it is a hydrocele what investigation might you order and why?

10 Q. If the swelling is solid not cystic what is your differential diagnosis? Q. If the ultrasound showed that this was an uncomplicated hydrocele how would you advise the patient? Case Study 6: A 30 year old man presents with a dull ache and heaviness in his left scrotum and a probable swelling. He and his partner have been trying to conceive unsuccessfully for 18 months. Q. What is your differential diagnosis? Q. How would you demonstrate a varicocele? Q. What effect can a varicocele have in fertility potential?

11 Q. The patient states that he and his partner are keen to achieve a pregnancy what would you do next? Q. The semen analysis findings are those of OAT syndrome. How would you manage this patient? Q. What treatment may be necessary? Case Studies 7: Female Incontinence SCENARIO a A 44 yr old woman presents with a 3 year history of worsening urinary incontinence. She wears 3 large incontinence pads per day. Q. What is the definition of urinary incontinence? Q. What sub types of urinary incontinence are there? Q. What is the definition of Stress Urinary Incontinence?

12 Q. What is the definition of Urge (Urgency) Incontinence? Q. In light of the preceding definitions, what specific questions will you ask this woman which may be relevant to her incontinence? SCENARIO b She admits to leaking on coughing, sneezing, walking quickly and occasionally during sexual intercourse. She does however also admit that occasionally she has a compelling desire to micturate but is unable to make it to the toilet before leaking. Q. How would you proceed from here? Q. What do you think is the primary diagnosis? Q. What would you do next? Q. If physiotherapy failed to improve things, what else might you consider? Q. If conservative measures fail to improve the patient s symptoms, what would you do next?

13 SCENARIO c Despite the fact that the woman s history suggested predominantly stress urinary incontinence, her urodynamics tracing showed a very overactive bladder. Q. What is the treatment of overactive bladder? Q. What are common side effects of anti cholinergic treatment? Q. In which underlying condition are anti cholinergic agents contra indicated? Q. If oral anticholinergic treatment fails, what other medical treatment is available?

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