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)
MANAGEMENT OF COMMON UROLOGICAL PROBLEMS IN GENERAL PRACTICE Dr Anna Lawrence, Urologist Mr Simon Van Rij, Urologist
WHO ARE WE Urologist Auckland Uro-Oncologist Robotic Urologist Urologist Auckland Neuro-Urologist, Current Clinical Lead ASRU Reconstructive Urologist plastic surgeon of penis
WHAT WE WILL COVER PSA Scrotal lumps, bumps and how to exam Recurrent Bladder Infections Haematuria Penile problems
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.
RECURRENT UTIS Defined as 3 + UTIs in 12months Dx clinically with: Dysuria Frequency Hematuria Urgency New onset incontinence
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
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.
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
RECURRENT UTIS : INVESTIGATIONS MSU: If abnormalities of urinary track known >3 UTIs a year Renal USS: Stones High post void residuals Possible Bladder ca
RECURRENT UTIS: MANAGEMENT BEHAVOURIAL MANAGEMENT Fluids (>1.5l) Voiding after intercourse Spermicides Avoid constipation No good research Showers Front to back Tampons
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
RECURRENT UTIS: MANAGEMENT SELF INITIATED: On the shelf at home 87% accuracy of infection Rule out other causes HIPREX (+Vit C) Bactoricial Acidic environment
RECURRENT UTIS: MANAGEMENT POST MENOPAUSAL: Consider topical or oral HRT
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
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
RECURRENT UTIS: MANAGEMENT UROMUNE: Sublingual immunomodulation Section 29 3/12 of x2 sublingual for? Length of protection
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
HAEMATURIA: MICRO: On microscopic analysis of urine MACRO: Gross Frank Clots bleeding Pink urine Cola urine
HAEMATURIA: Anticoagulation may exacerbate bleeding Haematuria should not be attributed solely to the patient being on anticoagulation Look for an underlying cause
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
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
MICROSCOPIC HAEMATURIA 3 or greater red blood cells per high powered field Malignancy rates widely vary for microhaematuria Best evidence is 3.3%
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
MICROSCOPIC HAEMATURIA: ONGOING CARE.
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
PENILE PROBLEMS 1. FIX IN A HURRY 2. TAKE TIME
FRACTURE Recognise: Immediate Detumescence +/- Pain Significant bruising/ Haematuria Late Presentation: Bruising Peyronie s disease ED
FRACTURE REFER EMERGENCY REQUIRES EARLY INTERVENTION Surgery within 4hours
FRACTURE Late Complications: Erectile Dysfunction Stricture Disease Peyronie s disease All >50% without intervention
PARAPHIMOSIS Recognise: Hx: Tight foreskin Catheter change Cleaning
PARAPHIMOSIS Foreskin retracted and unable to be return to normal Painful Swelling of retracted foreskin Auto-amputation if not treated
PARAPHIMOSIS Management: Emergency Refer but start some treatment Local anaesthetics Sugar Ice Manual reduction
PARAPHIMOSIS
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
PEYRONIE S DISEASE Management: Reassurance If not painful, and able to have intercourse Painful and worsening bend Bend so bad cannot have intercourse
PEYRONIE S DISEASE Management: No oral therapies Operations: Injectables: Xiaflex
ERECTILE DYSFUNCTION Recognise: Discussion that is a normal part of day to day discussion 40% at 40 years 70% at 70 years
ERECTILE DYSFUNCTION Management: Review Stress Medications Possible neurological disorders Anxiety Past/ present substance abuse weight
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
ERECTILE DYSFUNCTION INJECTABLES Bimix Trimix Alprostadil: pain Intraurethral also >80%men obtain firm erections Initiates
ERECTILE DYSFUNCTION
THANK YOU. Questions