4: UROLOGY

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CHAPTER 4 UROLOGY

Urinary tract infection (UTI)

Urinary incontinence

URINARY TRACT INFECTION (UTI)

The average GP with a list of 2000 patients will see 30–40 cases of UTI a year. UTIs are particularly common in sexually active women, older menopausal women and men with prostatic hypertrophy. They usually present with urinary frequency, dysuria and cloudy urine, and sometimes suprapubic pain or tenderness, haematuria, urinary incontinence, or acute retention of urine. Pyelonephritis may present with loin pain, fever, rigors and/or vomiting. Up to half of all non-pregnant women with symptoms of lower UTI have no detectable bacterial infection, and therefore drug treatment is often unnecessary.

Diagnosis

Examination.

Examination is usually unnecessary, but look for suprapubic or loin tenderness, if appropriate.

Management

Advise the patient to drink copious fluids, especially alkaline liquids, e.g. sodium bicarbonate or potassium citrate solution (available OTC).

Proteinuria and haematuria have many causes other than UTI. Negative urine tests for leucocytes and nitrite can reliably indicate that a UTI is not present.

First-line treatment of UTIs

Females with simple UTI.

Trimethoprim 200 mg bd or amoxicillin 250 mg tds for 3 days.

Children aged >12, men, and women with clinical evidence of renal involvement (e.g. fever, loin pain).

Trimethoprim 200 mg bd or amoxicillin 250 mg tds for 7–10 days. (Check dosage for young children.)

Management of recurrent UTIs in women

• If recurrent symptoms are due to the same organism, ensure that treatment is with an antibiotic to which the pathogen has been shown to be sensitive, check compliance and continue the antibiotic for 5–7 days.

• Consider topical oestrogen for peri- and postmenopausal women.

• Further investigations: consider blood tests (e.g. C&Es, fasting BS), a plain abdominal X-ray (to look for radio-opaque stones), followed by an ultrasound scan of the urinary tract or an IVU to exclude renal cortical scars from previous infections, or evidence of obstruction.

• If these investigations are normal, consider giving prophylactic antibiotics. One-quarter of the usual 24-hour dose should be given at night and continued until the urine has been sterile for 1 year, e.g. trimethoprim 100 mg nocte. Before starting on this regimen, consider referral for urological assessment.

• Patients whose UTIs are clearly related to intercourse may take a single dose of antibiotic within 2 hours of intercourse (e.g. nitrofurantoin 50 mg).

• Consider prescribing a ‘spare’ course of antibiotics for the patient to start at the onset of symptoms.

UTIs in men.

See management of UTIs in general (p. 65). Further investigations (see p. 65) should be arranged after a first confirmed UTI. Consider PSA if aged >40. In men with BPH, alpha blockers reduce the incidence of UTIs. Consider referring men with a confirmed UTI to a urologist.

Men with symptoms of a UTI but no infection may have prostatitis. They usually have discomfort behind the testicles. Prostatitis can be diagnosed by sending the first urine of the morning (the early part of the stream) for microscopy and confirming the presence of threads of white cells. Treat with e.g. trimethoprim 200 mg bd for 28 days, or longer if the symptoms have not completely settled.

UTIs in children.

Administration

Dipsticks for nitrite and leucocytes are not prescribable on FP10.

URINARY STONES

Ureteric colic usually presents with very severe unilateral loin pain, often radiating to the groin or genitalia, and often accompanied by vomiting. The diagnosis is confirmed by the presence of microscopic haematuria. Patients with undiagnosed backache or vague loin pain may be harbouring a stone.

Management

Treatment

• Most patients improve spontaneously without intervention due to spontaneous passing of the stone.

• Give diclofenac 75 mg im (or 100 mg PR) or pethidine 100 mg im, together with prochlorperazine 12.5 mg im, if required, for vomiting.

• Less severe pain can be controlled with e.g. oral NSAIDs or oral pethidine.

• Sieve urine to catch stone(s) for analysis.

• Push fluids.

URINARY INCONTINENCE

Incontinence is involuntary leakage of urine and is a common and disabling condition. It is estimated that as many as 60% of the elderly population and 40% of women over the age of 20 suffer from some form of urinary incontinence. It can be significantly improved by appropriate intervention, but is underdiagnosed because a large percentage of sufferers do not consult their doctor. Stress incontinence and urge incontinence are responsible for over 90% of cases of incontinence. The two often coexist, but the most useful distinguishing factor is the absence of urgency in stress incontinence.

Diagnosis

History.

It is important to take advantage of routine screening opportunities to identify sufferers.

• stress incontinence:

– leakage of urine with exercise, coughing or sneezing

• urge incontinence:

– urinary frequency, day and night

– hurrying to get to the toilet

– not being able to get to the toilet in time

• overflow incontinence (bladder outflow obstruction):

– difficulty passing urine (hesitancy)

– dribbling after passing urine

– poor stream

– a sensation of incomplete bladder-emptying

• passive incontinence:

– passing urine without knowing it

– accidents in bed at night.

General questions.

• dysuria (suggestive of UTI, atrophic vaginitis or obstruction).

• liquid intake (alcohol and coffee are diuretics).

• drugs, e.g. diuretics, antidepressants.

• the use of pads or towels.

• past history, e.g. stroke, dementia, Parkinson’s disease, multiple sclerosis, prolapsed disc, spinal injury, previous pelvic surgery, obstetric history, etc.

Investigations

• Dipstick urine for blood, sugar, protein, nitrite and leucocytes.

• MSU for MC&S.

• Consider blood for C&Es and fasting BS.

• A urinary diary, documenting frequency and volume of urine passed, and drinks taken, can be helpful.

Management

Most patients can be treated satisfactorily by the GP.

Stress incontinence.

(due to weakness of the urethral sphincter.)

• Encourage reduction of intra-abdominal pressure by:

– reducing weight, if appropriate

– stopping smoking, if appropriate

– avoiding constipation

– avoiding heavy lifting.

• Regular pelvic floor exercises (i.e. repetitive squeezing of the pelvic floor) improve tone and support. Tighten the front (bladder) and back (bowel) passages. Count to four slowly, then release slowly. Do this several times and repeat every hour or so, if possible. These exercises, which can be done at any time, and are not evident to others, should ideally be continued for life.

• Consider referral to a physiotherapist for instruction on pelvic floor exercises, treatment with graduated vaginal cones or electrical stimulation of the pelvic floor (faradism or interferential treatment).

• Consider referral for urodynamic investigations and/or surgery, e.g. transvaginal tape, colposuspension, if:

– the exact diagnosis is in doubt

– conservative methods have failed

– symptoms recur following surgery.

• Treat atrophic vaginitis with local oestrogen cream or systemic HRT.

Urge incontinence.

(due to detrusor instability)

• Bladder retraining involves encouraging the patient to void increasingly larger volumes of urine at less frequent intervals, thus relearning inhibition of abnormal detrusor muscle contractions.

• Drugs to stabilise the detrusor muscle can be used in addition to bladder retraining, e.g. oxybutynin 2.5–5 mg bd or tolterodine 1–2 mg bd (sustained release preparations reduce the anticholinergic side-effects). Once continence has been regained, many patients are able to sustain the improvement without medication.

• The patient may need psychological support.

Living with incontinence

• Refer to a district nurse for advice on appliances, e.g. incontinence pads.

• Consider involving local continence advisors.

PROSTATISM

Prostatism, or symptoms of outflow obstruction in men, is common, particularly in the elderly, and often not volunteered by the patient.

Diagnosis

History.

• poor urinary stream

• terminal dribble

• bone pain, which raises the possibility of malignant bony secondaries.

Examination.

• the enlarged bladder of urinary retention, which can be painless in chronic retention.

• enlargement of the prostate gland, by performing a DRE. (As a general rule, the malignant prostate is hard, craggy, irregular and often enlarged, with the central sulcus obliterated.)

Management

• Frequency and nocturia may be helped by a selective alpha blocker, e.g. indoramin 20 mg bd (relaxes smooth muscle, producing an increase in urinary flow rate).

• Refer for urological opinion in suspected malignancy, obstructive uropathy or symptoms of prostatism, which are resistant to treatment.

• For the patient too infirm for surgery, incontinence aids may become necessary. Consider monitoring C&Es in such patients, to detect obstructive uropathy.

• Catheterisation becomes necessary in acute retention, deteriorating renal function and as an alternative in incontinence control.

Patients significantly troubled by symptoms of prostatism should be offered referral, as a routine case, for consideration for surgery. Cases of malignancy, suspected on clinical or biochemical grounds, should be offered an urgent referral for tissue diagnosis.

Prevention/screening

There is much debate at present about the merits of screening for prostatic cancer. The three methods available are:

• regular digital examination

• transrectal ultrasound scanning

Although all methods should, in theory, enable the earlier detection of prostate problems, none has been shown so far to reduce mortality from prostate cancer.

Related

Churchills Pocketbook of General Practice