Urological common cases in GP practice

1. Mr. Noor Buchholz Consultant Urological Surgeon & Director Endourology and Stone Services Urological common cases in GP practice

2. 33 year old female Dysuria, frequency, cloudy urine No fever, no kidney pain No Hx of similar episodes Case 1

3. Wait for urine culture? • Imaging? • Refer to urology? • Immediate treatment? Case 1

4. Wait for urine culture? • Imaging? • Refer to urology? • Immediate treatment? • Dipstick sufficient Case 1

5. Wait for urine culture? • Imaging? • Refer to urology? • Immediate treatment? • Dipstick sufficient • Not needed Case 1

6. Wait for urine culture? • Imaging? • Refer to urology? • Immediate treatment? • Dipstick sufficient • Not needed • No Case 1

7. Wait for urine culture? • Imaging? • Refer to urology? • Immediate treatment? • Dipstick sufficient • Not needed • No • yes Case 1

8. Table 3.1: Recommended antimicrobial therapy in acute uncomplicated cystitis in otherwise healthy premenopausal women Case 1

9. Patient has come back with cystitis x3 over 8 months Each time ABX worked well Case 1

10. Urine culture? • Imaging? • Refer to urology? • Immediate treatment? Case 1

11. yes • Urine culture? • Imaging? • Refer to urology? • Immediate treatment? Case 1

12. Yes • Urography, cystography, cystoscopy not routinely – perhaps US KUB • Urine culture? • Imaging? • Refer to urology? • Immediate treatment? Case 1

13. Yes • Urography, cystography, cystoscopy not routinely – perhaps US KUB • Not in the abscence of risk factors • Urine culture? • Imaging? • Refer to urology? • Prophylactic treatment? Case 1

14. Table 2.1: Host risk factors in UTI (refer to urologist) RF = Risk Factor; * = not well defined; ** = usually in combination with other RF (i.e. pregnancy, urological internvention). Case 1

15. Yes • Urography, cystography, cystoscopy not routinely – perhaps US KUB • Not in the absence of risk factors • optional • Urine culture? • Imaging? • Refer to urology? • Prophylactic treatment? Case 1

16. Drink > 2.5 liters/ day • Acidification Cranberry/ Vitamin C 1 gram/ day • Genital hygiene pH-neutral alkaline-free soaps • Empty bladder +/- sex • General advise Case 1

17. Table 3.3: Continuous antimicrobial prophylaxis regimens for women with recurrent UTIs Case 1

18. Table 3.4: Postcoital antimicrobial prophylaxis regimens for women with recurrent UTIs “In appropriate women with recurrent uncomplicated cystitis, self-diagnosis and self-treatment with a short-course regimen of an antimicrobial agent should be considered “ Case 1

19. Behavioural and general advise as well as one-shot low-dose therapy worked well Patient presents 2 months pregnant worried about UTI’s and baby No acute signs of cystitis Asymptomatic bacteriuria ≥ 105cfu/mL Case 1

20. Another urine culture? • Imaging? • Refer to urology? • Treatment in the abscence of symptoms? Case 1

21. Another urine culture? • Imaging? • Refer to urology? • Treatment in the abscence of symptoms? • in an asymptomatic pregnant woman, bacteriuria is considered significant if two consecutive voided urine specimens grow ≥ 105cfu/mL of the same bacterial species on quantitative culture Case 1

22. Another urine culture? • Imaging? • Refer to urology? • Treatment in the abscence of symptoms? • in an asymptomatic pregnant woman, bacteriuria is considered significant if two consecutive voided urine specimens grow ≥ 105cfu/mL of the same bacterial species on quantitative culture • US KUB to exclude hydronephrosis – avoid Xray where possible Case 1

23. Another urine culture? • Imaging? • Refer to urology? • Treatment in the absence of symptoms? • in an asymptomatic pregnant woman, bacteriuria is considered significant if two consecutive voided urine specimens grow ≥ 105cfu/mL of the same bacterial species on quantitative culture • US KUB • If risk factors present (pregnancy can be regarded as a risk factor!) • Asymptomatic bacteriuria detected in pregnancy should be eradicated with antimicrobial therapy Case 1

24. Table 3.5: Treatment regimens for asymptomatic bacteriuria and cystitis in pregnancy G6PD = glucose-6-phosphate dehydrogenase Case 1

25. Figure 2.1: Traditional and improved classification of UTI as proposed by the EAU European Section of Infection in Urology (ESIU)

26. 45 year old male No symptoms On health check microhaematuria Case 2

27. Refer immediately to urology? • Further imaging? • Risk factors for Ca? Case 2

28. Refer immediately to urology? • Dipstick haematuria is a misnomer! • false-positive by hemoglobinuria, myoglobinuria, concentrated urine, menstrual blood, rigorous exercise • Always confirm by formal MSU – then refer Case 2

30. Further imaging? Case 2

31. Further imaging • May loose time in case of proven microhaematuria • One-stop haematuria clinic • CT – IVU & cystoscopy Case 2

32. Risk factors for Ca? Case 2

33. Risk factors for Ca? Case 2

34. Glomerular causes Alport's syndrome Fabry's disease Goodpasture's syndrome Hemolyticuremia Henoch-Schönleinpurpura Immunoglobulin A nephropathy Lupus nephritis Membranoproliferativeglomerulonephritis Mesangial proliferative glomerulonephritis Nail-patella syndrome Other postinfectiousglomerulonephritis: endocarditis, viral Poststreptococcalglomerulonephritis Thin basement membrane nephropathy (benign familial hematuria) Wegener's granulomatosis Nonglomerular causes Renal (tubulointerstitial) Acute tubular necrosis Familial Hereditary nephritis Medullary cystic disease Multicystic kidney disease Polycystic kidney disease Recognized Causes of Microscopic Hematuria

35. Infection: pyelonephritis, tuberculosis (e.g., travel to Indian subcontinent), schistosomiasis (e.g., travel to Africa) Interstitial nephritis Drug induced: penicillins, cephalosporins, diuretics, nonsteroidal anti-inflammatory drugs, cyclophosphamide (Cytoxan), chlorpromazine (Thorazine), anticonvulsants Infection: syphilis, toxoplasmosis, cytomegalovirus, Epstein-Barr virus Systemic disease: sarcoidosis, lymphoma, Sjögren's syndrome Loin pain–hematuria syndrome Metabolic Hypercalciuria Hyperuricosuria Renal cell carcinoma Solitary renal cyst Vascular disease Arteriovenous malformation Malignant hypertension Renal artery embolism/thrombosis Renal venous thrombosis Sickle cell disease Recognized Causes of Microscopic Hematuria

36. Extrarenal Benign prostatic hypertrophy Calculi Coagulopathy related Drug induced (warfarin [Coumadin], heparin) Secondary to systemic disease Congenital abnormalities Endometriosis Factitious Foreign bodies Infection: prostate, epididymis, urethra, bladder Inflammation: drug or radiation induced Perineal irritation Posterior ureteral valves Strictures Transitional cell carcinoma of ureter, bladder Trauma: catheterization, blunt trauma Tumor Other causes Exercise hematuria Menstrual contamination Sexual intercourse Recognized Causes of Microscopic Hematuria

37. 33 year old female Obese, blond Pain right upper abdomen after food Case 3

38. Imaging? Case 3

39. Imaging? • Questions to be asked? • US abdomen: • Gallstones • 2cm single simple cyst in left kidney Case 3

40. Imaging? • Further imaging? • Refer urology? • Follow up? • Treatment needed? • US abdomen: • Gallstones • 2cm single simple cyst in left kidney Case 3

41. Imaging? • Further imaging? Case 3

42. Imaging? • Further imaging? • CT-IVU if complex cyst or symptomatic only Case 3

43. Imaging? • Further imaging? • Refer urology? • If symptomatic and/ or complex cyst Case 3

44. Imaging? • Further imaging? • Refer urology? • Follow up? Case 3

45. Imaging? • Further imaging? • Refer urology? • Follow up? • If symptomatic and/ or complex cyst Case 3

46. Imaging? • Further imaging? • Refer urology? • Follow up? • Treatment needed? Case 3

47. Imaging? • Further imaging? • Refer urology? • Follow up? • Treatment needed? • If symptomatic and/ or complex cyst Case 3

48. Table 4: The Bosniak classification of renal cysts

49. 55 year old male Routine check-up PSA 5.8 No LUTS No family Hx of prostate cancer Case 4

50. Further diagnostics? Case 4