4: UROLOGY

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CHAPTER 4 UROLOGY

Urinary tract infection (UTI)
Proteinuria
Urinary stones
Urinary incontinence
Prostatism

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

History.

Ask about:

• the above symptoms
• previous history of UTI
• form of contraception.

Some other causes of UTI symptoms

• Atrophic vaginitis.
• Trauma from intercourse.
• Bladder outlet obstruction, e.g. prostatism.
• Soreness from e.g. deodorants.
• Genital infections, e.g. candida and chlamydia.
• Urethral syndrome (see p. 48).

Examination.

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

Investigations.

Dipstick urine to test for protein, nitrite (a bacterial metabolite) and leucocytes. If positive, treat for UTI.

An MSU for MC&S is usually unnecessary but should be sent in the following patient groups:

1. pregnant women
2. children
3. men
4. catheterised patients
5. patients who have failed to respond to initial antibiotic treatment
6. patients with persistent symptoms.

The MSU, taken prior to starting antibiotics, must show a pure growth in excess of 105 organisms/ml and white cells in excess of 50/mm3 in order to confirm a significant infection.

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.
• Discuss, if appropriate:

– increasing fluid intake
– urinating more frequently
– using a lubricant with intercourse
– passing urine after intercourse
– improving perineal hygiene
– avoiding tight clothing
– avoiding scented soaps, bubble bath, etc.
– contraception (e.g. a diaphragm may encourage UTIs).

• 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.

See p. 90.

Administration

Dipsticks for nitrite and leucocytes are not prescribable on FP10.

PROTEINURIA

A trace of proteinuria on dipstick, in the absence of microscopic haematuria, is nearly always benign.

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