UROLOGY TOPICS FOR SENIOR CLERKSHIP HEMATURIA Blood in urine is an important presenting symptom for many diseases of the urinary tract as well as for systemic disorders. Degree of hematuria has poor correlation with the seriousness of the underlying pathology. Pre- Requisites Enabling knowledge, skills and attitudes acquired prior to starting clinical rotations include: 1. Understanding that hematuria is a symptom rather than a disease and that cornerstone of evaluating a patient with hematuria is a thorough clinical history and how hematuria associated symptoms can localize the site and or cause of hematuria. 2. Knowledge of Symptoms and Signs of the most common causes of blood in urine like: genitourinary tract infections, urinary tract stones, trauma and genitourinary tumours 3. Knowledge of the common histological types of renal and bladder tumors Learning objectives: Knowledge: 1. List causes of hematuria including systemic diseases that cause blood in urine. 2. Discuss the relevant investigations for a patient with hematuria. 3. Discuss the risk factors for renal and bladder tumors 4. Discuss the management of renal tumors and understand why biopsy of the lesion is not a routine prior to surgical resection 5. Discuss the current indications for partial nephrectomy and radical nephrectomy in the management of renal tumors. 6. Discuss the approach to a patient with growth in the urinary bladder.
7. Understand the drastic difference in the management of a nonmuscle invasive and muscle invasive bladder tumors 8. Discuss the follow up of a patient with superficial bladder tumor 9. Discuss the urinary diversion procedures after radical cystectomy. Skills Student should demonstrate specific skills including: History-taking skills: 1. Establish whether hematuria is initial, terminal or total. 2. Elicit history of associated symptoms like pain abdomen, dysuria, irritative voiding symptoms, passing clots, fever, oliguria, edema, arthritis, rash and weight loss. 3. Elicit h/o smoking, exercise, medications, diet, bleeding disorder, renal stone disease, travel outside and Occupational exposure. Physical examination: 1. Demonstrate bimanual palpation of bladder tumor 2. Demonstrate checking for dullness in the renal angle Differential diagnosis: 1. Understand that painless hematuria and hematuria in patients older than 40 yrs are more likely to be associated with malignancy. Investigations: 1. Appreciate the importance of reviewing medications and allergies and documenting normal renal function before the use of contrast agents. 2. Discuss the appropriateness of Dipstick, urine microscopy and culture, CBC, urea and electrolytes, urine cytology, Ultrasonography of abdomen and pelvis, IVU, NCCT, CT Urography, RGP, Cystoscopy, Ureterorenoscopy and biopsy in a given patient. Communication skills:
1. Counsel and educate patients about use of urostomy bag 2. Counsel and educate patients on the importance of regular follow up after TURBT. Procedure skills 1. Students should be able to perform and teach Clean intermittent catheterisation. Management skills: 1. Plan appropriate investigations to reveal the cause of hematuria depending on the clinical scenario and discuss the advantages and disadvantages of the chosen modality. 2. Recognize the indications of referring a patient with haematuria to a specialist. Attitudes and Professional Behaviors: 1. Diagnosis of renal or bladder tumor is devastating news for the patient and relatives. Physician should show understanding and should learn to break bad news by participating in these sessions as observers. Delivery shell: 1. Clinical case presentations and bed side teaching 2. Problem based seminars 3. On call duties 4. Attending procedures in operation theater 5. Self learning
SCROTAL MASS Pre-requisites: Students should have the knowledge of 1. Differences in the lymphatic drainage of scrotal wall and testis, 2. Common pathological swellings of testis, epididymis and spermatic cord, 3. Differential diagnosis of acute and chronic scrotal swellings. Learning objectives: At the end of the session students should be able to Knowledge: 1. Discuss the common types of testicular tumors in relation to age. 2. Discuss commonly used investigations for evaluating scrotal mass. 3. Discuss the usefulness of tumor markers in the management of testicular mass. 4. Understand that most palpable testicular swellings are malignant in contrast to epididymal masses which are benign, 5. Discuss the treatment of testicular tumors according to the clinical stage. Skills History taking: 1. Understand that proper history is key to differentiate between scrotal masses, 2. Elicit history of urethral discharge, lower urinary tract symptoms and sexual contact 3. Elicit marital history including number of children and desire to have more children Physical examination:
1. Appreciate the importance of examining a patient with scrotal/inguinal swellings, both lying down and standing. 2. Demonstrate how to differentiate between true scrotal swellings and Inguinoscrotal swellings. 3. Demonstrate how to differentiate between solid and cystic swellings 4. Demonstrate checking for fluctuation and trans-illumination 5. Demonstrate testicular palpation. 6. Demonstrate palpation of para-aortic lymph nodes Differential diagnosis: 1. Propose differential diagnosis for solid scrotal swellings. Investigations: 1. Choose appropriate investigations for a patient with scrotal mass. Communication: 1. Discuss the impact of radiation and chemotherapy on future fertility. 2. Discuss cryopreservation of sperms with patient and partner. 3. Obtain necessary consent for a patient undergoing scrotal surgery. 4. Spread awareness for early treatment of scrotal conditions Attitude: 1. Understand the importance of ensuring privacy during sexual history taking, external genitalia examination and the need for a chaperone during examination. Delivery shell: 1. Clinical case presentations and bed side teaching 2. Problem based seminars 3. On call duties 4. Attending procedures in operation theater 5. Self learning
LOWER URINARY TRACT OBSTRUCTION Pre-requisites: The student should be able to: 1. Discuss the common causes of bladder outlet obstruction in male and female 2. Differentiate between acute and chronic urinary retention and explain the difference in their management 3. Explain obstructive and irritative lower urinary tract symptoms 4. Discuss the consequences of bladder outlet obstruction. 5. Discuss the importance of S.PSA 6. The student should have knowledge of Hypothalamus- Pituitary Gonadal axis. Learning objectives: At the end of session, student should be able to Knowledge: 1. Explain the current medical management of BPH 2. Discuss the surgical management of BPH 3. Discuss the immediate and late complications of TURP 4. Discuss diagnosis and staging of Carcinoma Prostate 5. Discuss the implication of Gleason grading and score 6. Discuss the management of early prostate cancer 7. Discuss the common side effects of surgery and radiotherapy for Ca Prostate 8. Discuss the management of advanced prostate cancer 9. Discuss the complications of androgen deprivation therapy. 10. Discuss the current status of Screening for prostate Skills History taking:
1. Elicit history of LUTS 2. Know the importance of family history of Carcinoma Prostate Physical Examination: 1. To detect palpable bladder 2. Do Digital Rectal Examination (DRE) to appreciate anal tone, prostate size and consistency, nodularity and any rectal mass lesions, 3. Check anal tone and perianal sensations to identify neurogenic bladder Management: 1. Plan appropriate investigations for a patient presenting with poor stream or urinary retention. 2. Interpret uroflowmetry tracing. 3. Discuss the approach to a patient with high S.PSA. 4. Do safe urethral Foley catheterization. 5. Know the indication for Suprapubic catheterization (SPC). Communication skills: 1. Importance of eliciting history of co-morbidities and drug intake such as aspirin. 2. Importance of informing the patient of retrograde ejaculation while planning TURP. 3. Counsel a patient worried by a news paper article on high incidence of Carcinoma Prostate, 4. Discuss the impact on erectile function and urinary incontinence with curative treatment of Carcinoma Prostate. Attitude: 1. Compassionate towards patients who are mostly elderly. Delivery shell: 1. Bed side teaching. 2. Problem Based Seminars. 3. Self learning. 4. Practicing DRE on mannequin. 5. Attending Urology OR and urology OPD.
Genito Urinary Trauma Kidneys are most commonly involved in Genito urinary trauma, which may be from blunt injury or penetrating injury. Urethral injuries are common in men in association with straddle injury or pelvic fracture. Pre- Requisites Enabling knowledge, skills and attitudes acquired prior to starting clinical rotations include: 1. Anatomy of Genito-urinary system. 2. Factors that make children more prone for renal injuries 3. Principles of resuscitation of a trauma patient Learning objectives: Knowledge: 1. Discuss the common sites of urethral injury in trauma 2. Explain how straddle injury results in injury to bulbar urethra. 3. Explain how fracture pelvis results in posterior urethral/ bladder injury. 4. Discuss the relevant investigations for a patient with suspected urethral injury. 5. Discuss the management of bulbar urethral injury and potential complications. 6. Discuss the management of posterior urethral injury and potential complications 7. Discuss the relevant investigations for a patient with suspected bladder injury. 8. Discuss the difference in the management of intraperitoneal and extraperitoneal bladder injuries. 9. Discuss the investigations for a suspected renal injury. 10. Understand that most renal trauma can be managed conservatively. 11. Understand that ureteric injury is usually iatrogenic 12. Discuss the management of testicular trauma 13. Understand the mechanism of blunt penile injury and clinical presentation.
Skills Student should demonstrate specific skills including: History-taking skills: 1. Establish the nature of injury. 2. Obtain history of underlying renal anomalies like hydronephrosis/ cystic diseases. Physical examination: 1. Look for evidence of fracture pelvis, fracture ribs, skin bruises and perineal hematoma 2. Look for blood at the external urethral meatus and urinary retention. Differential diagnosis: 1. Understand that significant urinary tract injury can be present in the absence of hematuria and that degree of hematuria does not correlate with the severity of the injury. 2. Renal injury should be considered in all penetrating injury to the flank. Investigations: 1. Understand that all trauma patients with blood at the meatus should have retrograde urethrogram to r/o urethral injury 2. If Foley catheter drains blood stained urine, bladder injury should be ruled out. Management skills: 1. Know that urethral catheterization should be avoided in suspected urethral injury 2. Know that life threatening hypovolvemia can occur with pelvic fractures. 3. Know that associated injury to other intra abdominal organs is common. Attitudes and Professional Behaviors: 1. Team work is important in the resuscitation and management of trauma patients.
INFERTILITY Incidence of infertility is on the rise worldwide causing distress to 15-20% of couples. Male and combined male female factors are responsible in about 50% of cases. Pre- Requisites Enabling knowledge, skills and attitudes acquired prior to starting clinical rotations include: 1. Anatomy and physiology of the male genital tract. 2. spermatogenesis 3. Chromosomal abnormalities causing male infertility 4. Hypothalamus- pituitary- Gonadal axis Learning objectives: Knowledge: 1. Define infertility 2. Discuss the causes of male infertility. 3. Understand that about 50% of cases of male infertility are idiopathic. 4. Plan investigations for an infertile male. 5. Identify the indications for endocrine evaluation in an infertile male 6. Discuss the indications for testicular biopsy 7. Discuss the significance of finding Varicocele in an infertile male. 8. Discuss the surgically correctable causes of male infertility 9. Discuss the common causes of obstructive azoospermia 10. Discuss assisted reproductive techniques for the treatment of male infertility. 11. Discuss sperm retrieval techniques for IVF/ICSI
Skills Student should demonstrate specific skills including: History-taking skills: 1. Identify factors like mumps, urethritis and inguinal surgery which impact fertility. 2. Elicit h/o smoking, medications and Occupational exposure to gonadotoxins. Physical examination: 1. Demonstrate examination of external genitalia and assessment of testicular size. 2. Demonstrate checking for Varicocele. Investigations: 1. Discuss investigation of an infertile male. 2. Discuss the role of testicular biopsy Communication skills: 1. Counsel and educate patients about prevention of infertility 2. Take consent for correction of Varicocele highlighting the limitations on outcome 3. Counsel and educate patients on the importance of sperm banking prior to chemotherapy. Procedure skills 1. Students should be able to advice patients on proper collection of specimen for semen analysis. Management skills: 1. Plan appropriate treatment of obstructive azoospermia. 2. Recognize the indications of referring a patient for assisted reproductive techniques.
Attitudes and Professional Behaviors: 1. Diagnosis of noncorrectable causes of infertility is devastating for the patient and relatives. Physician should show understanding and should learn to break bad news by participating in these sessions as observers. 2. Understand that when there is conflict between the wishes of the couple and the interests of the future child, it may be ethically correct to withhold therapy Delivery shell: 1. Clinical case presentations and bed side teaching 2. lecture 3. Attending procedures in operation theater 4. Self learning ERECTILE DYSFUNCTION Erectile dysfunction is the inability to achieve and maintain an erection sufficient to permit mutually satisfactory sexual intercourse. Erectile dysfunction impacts quality of life and cause distress to couples. Pre- Requisites Enabling knowledge, skills and attitudes acquired prior to starting clinical rotations include: 1. Anatomy and physiology of the male genital tract. 2. Physiology of erection. 3. Hypothalamus- pituitary- Gonadal axis Learning objectives:
Knowledge: 1. Discuss the causes of erectile dysfunction. 2. Understand that majority of the cases of erectile dysfunction are due to organic causes. 3. Plan investigations for a male with erectile dysfunction. 4. Discuss the treatment options for erectile dysfunction. 5. Discuss the rationale for use of PDE5I. 6. Explain why PDE5I are contraindicated in patients on nitrates. 7. Discuss the surgical treatment of erectile dysfunction. 8. Discuss the common causes of ejaculatory dysfunction. Skills Student should demonstrate specific skills including: History-taking skills: 1. Identify risk factors like smoking, diabetes, hyperlipidemia, medications and pelvic surgery, which impact erectile function. 2. Should assess the cardiac fitness of patients prior to treating ED. Physical examination: 1. Demonstrate examination of external genitalia and assessment of testes. 2. Demonstrate checking for secondary sexual characteristics. Investigations: 1. Discuss investigation of a male with erectile dysfunction 2. Discuss the role of intracavernosal injection of vasodilatory drugs. Communication skills: 1. Counsel and educate patients on proper use of PDE5I 2. Take consent for penile implant surgery Procedure skills 1. Students should be able to advice patients on proper technique of intracavernosal injection. Management skills:
1. Modern treatment of ED has been revolutionized by the availability of PDE5 inhibitors for oral use, which are associated with high efficacy and safety rates, 2. Treatment options for patients not responding to oral drugs (or contraindicated) include intracavernous injections, vacuum constriction devices and implantation of penile prosthesis. 3. Recognize the indications of referring a patient for penile implant. Attitudes and Professional Behaviors: 1. When evaluating male with ED, remember that the partner plays an integral role. 2. If successful and effective management is to occur, any discussion of treatment should include the couple Delivery shell: 1. Clinical case presentations and bed side teaching 2. lecture 3. Attending procedures in operation theater 4. Self learning