GP Guidelines

 

Androgen deficiency

Definition:

Men with symptoms & signs of low testosterone levels

Advice:

Does not usually require urological referral

Contents:

      • Diagnosis
      • When to refer
      • Indications for testosterone
      • Contraindications for treatment
      • Monitoring treatment
      • Useful links

Diagnosis:

Testosterone is released in pulses during the day. Measure morning total testosterone levels between 8 and 10 am on 2 different mornings. A select few men may require free (bioavailable) testosterone levels.

When to refer:

Referral is considered appropriate for men who have consistent symptoms & signs with proven low serum testosterone levels.

Indications for treatment:

Testosterone replacement therapy is required in the following:

  • to induce & maintain secondary sex characteristics
  • to improve sexual function & libido
  • to improve general malaise
  • to increase muscle mass & muscle strength
  • to increase bone mineral density

Contra-indications for treatment:

  • breast cancer
  • prostate cancer
  • palpable prostate nodule
  • high age reference PSA (requires urological evaluation)
  • erythrocytosis (PCV > 50%)
  • untreated obstructive sleep apnoea
  • severe LUTS with IPSS > 19/35
  • class III or IV heart failure

Monitoring treatment:

Aim to achieve testosterone levels in the mid-normal range.

Useful Links: 

Endocrine Society Testosterone Therapy in Adult Men with Androgen Deficiency Syndromes

http://www.endocrine.org/education-and-practice-management/clinical-practice-guidelines

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Balanitis

Definition:

Inflammation of the penis & foreskin.

Advice:

Do not usually require urological referral. Can be managed in primary care with simple antibiotics and local cleansing of the foreskin. Refer if failure to resolve or has phimosis

When to refer:

      • Failure of resolution or phimosis
      • Recurrent balanitis in the absence of phimosis may warrant a referral to Dermatology or GUM clinic
      • If you suspect penile cancer, please refer as UCR to urology

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Balanitis Xerotica Obliterans

Definition:

Chronic, progressive dermatological condition affecting male genitalia

Advice:

May be asymptomatic. Refer if refractory to topical steroids

Contents:

Clinical Information

Management

Clinical information:

      • May be asymptomatic
      • Characterized by thickened, discoloured, white foreskin which may become adherent to glans
      • Known as lichen sclerosis elsewhere in the body
      • Possible complications include phimosis, meatal or urethral stricture, difficulty with intercourse
      • It is not cancer, not contagious & not sexually transmitted

Management

      • Topical steroid creams are 1st line
      • Treat secondary infection
      • Circumcision for phimosis
      • May require surgery for meatal dilatation

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Catheter problems

Advice:

Most problems can be resolved in the community by washing out the bladder or changing the catheter. Please replace a suprapubic catheter that has fallen out urgently, else the track will be lost

Contents:

      • Catheter changes
      • Catheter blockages
      • Leakage around the catheter
      • Catheter expulsion
      • Other catheter related concerns
      • General advice for patients

Catheter changes:

      • Long term catheters should be replaced every 10-12 weeks
      • Use the smallest size catheter where possible

Catheter blockages:

      • Exclude kinks in the catheter or drainage system
      • Ensure drainage bag is lower than the bladder
      • Try regular bladder washouts
      • Ensure adequate fluid intake as smaller volumes of urine can cause higher concentration of debris, which leads to blockages
      • If the problems continues, check for bladder stones with a plain abdominal X-ray
      • Avoid constipation

Leakage around the catheter:

This may be due to a blocked catheter (see above) or unstable bladder contractions. The latter can be managed with anti-cholinergic medication. Reducing the amount of fluid in the balloon may also help reduce spasms. In women, a long term urethral catheter can cause erosion of the bladder neck, leading to leakage around the catheter. Changing the catheter to a larger one will increase the erosion further. Consider a long term suprapubic catheter in this situation. Patients should rarely be sent home from hospital with 3-way catheters unless specifically requested by one of the urology consultants. In this situation a plan should be in place for their removal.

Catheter expulsion:

Replace both urethral & suprapubic catheters as soon as possible. In the case of suprapubic catheters, this is urgent to reduce the risk of closure of the track.

Other catheter related concerns:

      • Bleeding
      • Traumatic hypospadias (erosion of the glans penis in men)
      • Peri-urethral abscesses
      • Skin tags may form around suprapubic sites. These come & go, but can be treated with silver nitrate if they become a problem

General advice for patients:

      • Patients can have sexual activity with a suprapubic catheter
      • Patients can go swimming with catheters but should be advised to keep catheter sites clean afterwards
      • Advise patients to alternate the leg they wear the drainage bag on to minimise soreness at the site

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Clean Intermittent Self Catheterization

Definition:

Means of emptying the bladder when it is unable to contract or in patients with loss of appropriate co-ordination between the bladder muscle & the external urethral sphincter by using a clean catheter

Advice:

Usually taught by specialist urology nurses

Contents:

      • How to do CISC
      • Advice for patients

How to do CISC:

      • Usually performed every 5-6 hours
      • Wash hands & urethra with soap & water
      • Women may need to use a mirror to help locate the meatal opening
      • Lubricate the tip of the catheter as required using water-soluble jelly. Most catheters are self-lubricated
      • Insert the catheter until urine flows (approx 2-4 inches)
      • Clean & store the catheter although many catheters are now single use

Advice for patients

      • Catheters should be cleaned with soap & water immediately after use
      • Rinse thoroughly & air dry
      • Replace catheters weekly or sooner should they crack, become brittle or have build up of sediment
      • Advise patients to avoid constipation
      • High fibre diet is advised
      • Drink at least 8 glasses of fluid a day
      • If patients are going abroad, it may be advisable to give them a letter for Customs Officials stating that they require catheters
      • Patients should be advised to use bottled water if they are visiting countries where water quality is in doubt
      • Patients should also be advised to take catheters in their hand luggage when going abroad as suitcases can get mislaid

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Cystitis (acute)

Definition:

Acute infection of the bladder +/- kidney involvement (pyelonephritis)

Advice:

Does not usually require referral unless unresolving pyelonephritis

Contents:

      • Women
        • Useful advice for patients
        • Conservative advice to give patients to prevent recurrent symptoms
      • Men
        • Acute pyelonephritis

Women:

Treat with 3-7 day course of antibiotics. Urological referral is not generally indicated for a single infection. Women with recurrent UTIs should be referred. An ultrasound of the renal tract with a residual volume measurement organized in primary care is always very helpful.

Useful advice for patients:

      • As soon as patients start to feel symptoms of cystitis coming on, they should start to drink plenty of fluids.
      • Advise patients to avoid bladder irritants whilst symptomatic (coffee, tea, alcohol)
      • Suggest 1 tablespoon of bicarbonate of soda dissolved in water as soon as possible to reduce urinary acidity. This should help reduce the stinging. Repeat as necessary every 3-4 hours.
      • A hot water bottle on the abdomen or between thighs may help reduce the discomfort.
      • Simple analgesics such as Paracetamol or Aspirin may help

Conservative advice to give patients to prevent recurrent symptoms:

      • Drink 3-4 pints a day
      • Advise patients to keep clean ‘down below’ using a separate flannel/ towel
      • Wipe from front to back
      • Avoid bubble baths, talcum powder, vaginal deodorants, feminine wipes
      • A shower is better than a bath
      • Wash after intercourse if symptoms are precipitated by this activity
      • Suggest lubrication such as KY Jelly during intercourse – this is available for patients from most chemists without needing a prescription
      • Suggest voiding after intercourse
      • Cranberry preparations mat help prevent further infections (avoid in Multiple Sclerosis or if taking warfarin)

Men:

It may be helpful if an ultrasound of the renal tract has been arranged prior to consultation.

Indications for referral include:

      • Failure to respond to appropriate antibiotic treatment
      • An underlying cause, especially if over 45 years of age, such as bladder outlet obstruction
      • 2 or more UTIs in a 3 month period
      • History of stones
      • Previous genitourinary tract surgery

Acute pyelonephritis:

Suggested by flank pain, nausea & vomiting, fever (> 38 degrees C), & can be in the absence of cystitis like symptoms. Most patients can be managed at home. Generally a 10-14 day course of appropriate antibiotics is sufficient. However, those who have severe symptoms may require admission for parenteral antibiotics. Patients can take up to 6 weeks to recover from acute pyelonephritis.

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Cystitis (chronic)

Definition:

Recurrent bladder infections. More common in women than men.

Advice:

Refer if simple measures fail to resolve symptoms

Contents:

      • Antibiotic prophylaxis
      • Drugs to avoid
      • Preventative advice
      • When to refer
      • General information

Antibiotic prophylaxis:

Consider low dose prophylactic antibiotics such as Trimethoprim, Cephalexin or Nitrofurantoin. A plan abdominal X-ray & renal tact ultrasound should be considered before starting treatment. It is worth asking for a residual volume to be done at the time of the ultrasound. A large residual volume in post-menopausal women may respond to urethral dilatation.

Drugs to avoid:

Trimethoprim should be avoided in the 1st trimester of pregnancy

Nitrofurantoin should be avoided long term due to the risk of haemolysis or if the patient is G-6PD deficient.

Preventative advice:

• Drink 3-4 pints a day

• Advise patients to keep clean ‘down below’ using a separate flannel/ towel

• Wipe from front to back

• Avoid bubble baths, talcum powder, vaginal deodorants, feminine wipes

• A shower is better than a bath

• Wash after intercourse if symptoms are precipitated by this activity

• Suggest lubrication such as KY Jelly during intercourse – this is available for patients from most chemists without needing a prescription

• Suggest voiding after intercourse

• Cranberry preparations mat help prevent further infections (avoid in Multiple Sclerosis or if taking warfarin)

When to refer:

Consider referral in the following situations:

      • women with recurrent cystitis despite conservative measures
      • men with 2 or more UTIs in 3 months
      • pregnant women
      • patients with associated episodes of pyelonephritis
      • diabetic patients
      • patients with known urinary tract abnormalities or previous surgery
      • patients with known urinary stones
      • patients with known urinary tract malignancy

General information:

      • It is important to have all MSU results attached to the referral letter to help manage patients
      • Recurrent cystitis may be a presentation of bladder malignancy, especially in the older population
      • Urine cultures are recommended for those with:
        • suspected acute pyelonephritis
        • symptoms that do not resolve or recur within 2-4 weeks after the completion of treatment
        • those women who present with atypical symptoms
      • Patients with long term catheters do not necessarily require treatment unless patients are symptomatic

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Ejaculatory Problems

Definition:

There are many types of ejaculatory disturbances as defined below

Advice:

Does not usually require referral

Impaired ejaculation:

This does not usually have a physical cause. If the patient has symptoms of voiding and associated delayed ejaculation, this may suggest a urethral stricture and a referral to any urologist should be considered. However, in the majority of patients, a urological referral is not indicated.

Retrograde ejaculation:

This refers to when semen enters the bladder instead of through the penis at ejaculation. The following can cause this condition, which is generally harmless, although can cause male factor infertility:

      • Surgery such as bladder neck incision or TURP
      • Blood pressure medication or alpha-blockers, used for enlarged prostates
      • Nerve damage caused by diabetes, multiple sclerosis, or spinal cord injury

Urological referral is seldom necessary. If fertility is compromised, then consider referral to a fertility unit.

Premature ejaculation:

One of the most common sexual problems with no underlying urological cause. Please consider referral to a Psycho-Sexual Counsellor if required.

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Epididymal Cysts

Definition:

Smooth spherical benign cyst in the head of the epididymis

Advice:

Refer if significant discomfort or large cyst causing cosmetic embarrassment

Contents:

      • Investigations
      • Management
      • When to refer

Investigations:

      • Scrotal ultrasound if there is diagnostic uncertainty

Management:

      • Antibiotics are not indicated
      • Treatment is not usually required – explanation & advice is often all that is needed
      • Aspiration of fluid is not recommended due to the high risk of recurrence & infection
      • Asymptomatic patients can be reassured
      • Epididymal cysts can cause pain, which tends to settle

When to refer:

      • Significant discomfort
      • Large increasing size causing symptoms
      • Cosmetic embarrassment (due to cluster of cysts or large size)

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Epididymitis

Definition:

Inflammation of the epididymitis. Can be acute or chronic

Advice:

Usually requires referral

Contents:

      • Investigations
      • Men under 45 years
      • Men over 45 years
      • Indications for referral

Investigations: 

      • Send urine for M, C & S
      • GUM clinic referral for men under 45 years
      • May need ultrasound scrotum

Men under 45 years:

      • Treat with ciprofloxacin & doxycycline or ofloxacin alone for 2 weeks, depending on urine cultures
      • Refer to GUM clinic for STD screening & contact tracing

Men over 45 years:

      • Treat with ofloxacin or ciprofloxacin with doxycycline
      • Ensure urine sent for culture
      • Consider TB if:
        • failure to resolve
        • chronic abscess formation
        • discharge through scrotal skin

When to refer:

      • Symptoms not settled after 2 weeks of treatment
      • Systemic symptoms
      • Significant lower urinary tract symptoms

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Erectile Dysfunction

Definition:

Inability to achieve and/ or maintain an erection adequate for sexual function

Advice:

Refer if oral therapy is ineffective, contraindicated or not tolerated

Contents:

      • Risk factors
      • Management in Primary Care
      • Serum testosterone
      • When to refer
      • Schedule 11 restrictions

Risk Factors:

      • Age over 50 years
      • Diabetes
      • Hypertension
      • High cholesterol
      • Smoking
      • Cardiovascular disease
      • Excessive alcohol intake

Management in Primary Care

Most patients with erectile dysfunction can be managed in primary care with the following:

      • Exclude treatable causes such as hormone abnormalities
      • Treat modifiable factors:
        • Lifestyle
        • Relationship problems
        • Drugs
        • Smoking
        • Excessive alcohol
        • Depression
      • Start oral therapy with one of the following providing there are no contraindications:
        • Sildenafil 50mg
        • Tadalafil 10mg
        • Vardenafil 10mg

Serum testosterone:

        • Indicated when serum testosterone is low
        • Only indicated on advice of endocrinologist
        • Not indicated in men with normal serum testosterone
        • Testosterone is best measured in the mornings when levels are at their highest
        • Options include injections, gel or patches.
        • Regularly monitor serum testosterone during treatment

When to refer:

        • When oral medication is contra-indicated, ineffective or not tolerated
        • Refer patients for any of the following options:
          • Self-injection of alprostadil
          • MUSE (medicated urethral system for erection)
          • Vacuum erection assistance devices

Schedule 11 restrictions:

All treatments are subject to Schedule 11 restrictions. Only patients with the following conditions can obtain treatment on the NHS:

      • Diabetes Mellitus
      • Spinal cord injury or pelvic injury
      • Multiple sclerosis
      • Poliomyelitis
      • Prostate cancer
      • Severe psychological distress
      • Renal failure
      • Single gene neurological disorders
      • Spina bifida
      • Surgery (prostatectomy & radical pelvic surgery)

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Foreign Bodies

Definition:

Introduction (usually self) of any object through the urethra

Advice:

Requires urgent admission

 

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Fournier’s Gangrene

Definition:

Polymicrobial necrotizing fasciitis of the perineal, perianal or genital areas

Advice:

Requires urgent admission

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Haematospermia

Definition:

Blood in semen

Advice:

Urological referral rarely indicated

Contents:

      • Clinical information
      • Management

Clinical information:

      • Can be bright red if recent bleeding or red/brown if old
      • Usually benign & self-limiting
      • Exclude prostate cancer in men over 40 years of age

Management:

      • Usually resolves spontaneously & so requires no more than reassurance
      • Refer if associated with Haematuria
      • Treat with 6-8 weeks of NSAIDs & /or ofloxacin
      • Semen culture can be misleading due to contamination by urethral organisms

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Haematuria

Definition:

Blood in the urine

Advice:

Refer to the Haematuria referral criteria

Contents:

      • Classification of Haematuria
      • Risk of cancer
      • Visible Haematuria
      • Non-visible Haematuria
      • Indications for Nephrology referral
      • UCR Haematuria clinic

Classification of Haematuria:

      • Visible Haematuria (VH)
        • blood seen by patient
        • previously called frank or macroscopic
      • Non-visible haematuria (NVH)
        • prevalence of 5% in population
        • defined as ≥ 1+ on dipstick
        • trace of blood is NOT significant
        • no distinction required between haemolysed or non-haemolysed
        • can by symptomatic & associated with LUTs or loin pain
        • may be asymptomatic
        • you do not need to confirm urine microscopy in the laboratory

Risk of cancer:

      • approx 24% risk of cancer with VH
      • approx 9.4% risk of cancer with NVH

 

Visible haematuria:

      • exclude the following :
        • UTI
        • contamination during menstruation
        • transient causes – exercise haematuria, myoglobinuria, calculi, rifampicin, doxorubicin
      • for single episode of VH, treat infection & check urinalysis after treatment
        • if negative – no referral required
      • recurrent or persistent UTI + VH – refer as UCR to haematuria clinic
        • 5% of patients with bladder cancer present with recurrent UTIs
      • Gross, painless VH requires urgent UCR referral to the haematuria clinic

 

Non-visible haematuria:

      • exclude UTI, contamination, etc as above
      • treat UTI & check urinalysis after treatment
        • if negative urinalysis after treatment, no referral is required
      • persistent NVH is defined as 2 out of 3 dipsticks positive done at weekly intervals within 1 month
      • if persistent, asymptomatic NVH – suspect intrinsic renal disease & refer to nephrology if 1 or more of the following are found, especially if patient < 50 years of age:
        • declining GFR – by > 10ml/min at any stage within past 5 years or by > 5ml/min within the last year
        • Stage 4 or 5 CKD – eGFR < 30 ml/min
        • isolated haematuria without proteinuria & with hypertension in patients < 40 years
      • If above investigations are normal, consider the following:
        • persistent, asymptomatic NVH under 50 years of age with risk factors for bladder cancer (smoking, occupational exposure, cyclophosphamide) – refer to urology out-patients
        • persistent, asymptomatic NVH over 50 years of age, refer urgently to UCR haematuria clinic
        • symptomatic NVH at any age – urgent UCR referral to haematuria clinic

Indications for Nephrology referral:

      • decreasing eGFR:
        • > 10ml/min over 5 years, or
        • > 5ml/min over 1 year
      • Stage 4 or 5 CKD with eGFR < 30ml/min
      • Isolated NVH with hypertension, especially if < 40 years of age
      • VH coinciding with intercurrent (usually chest) infection
      • Patient < 16 years of age

UCR Haematuria one stop clinics:

      • Clinical history
      • Examination, including DRE
      • Blood tests, including PSA if not done within the previous 3 months
      • Ultrasound renal tract
      • Flexible Cystoscopy under local anaesthetic
      • Urine cytology is no longer routinely done in this clinic

At the end of this clinic, patients will be given a management plan. Patients diagnosed with bladder cancer will be given a date for their operation prior to discharge

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Hydrocoele

Definition:

Accumulation of fluid around a testicle

Advice:

Does not usually require urological referral

Contents:

      • Investigation
      • Clinical information
      • When to refer

Investigation:

      • Ultrasound may be helpful if there is doubt about the diagnosis

Clinical information:

      • Asymptomatic hydrocoeles do not require referral or treatment
      • Please do not refer simply for reassurance
      • Aspiration alone is not recommended due to the high rate of recurrence & the risk of infection

When to refer:

      • Symptomatic hydrocoele:
        • pain
        • directional voiding difficult
        • clothes don’t fit as hydrocoele too large
      • Abnormal testis or epididymis on ultrasound
      • If ultrasound shows a hydrocoele secondary to a testicular mass, then please refer urgently

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Hypospadius

Definition:

Urethral opening may be anywhere along shaft of penis. Usually congenital but may be acquired in men with traumatic hypospadius in the presence of a long term urethral catheter

Advice:

Referral in adults indicated for symptoms or cosmetic reasons

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Incontinence – Female:

Definition:

Leakage of urine

Advice:

May benefit from initial referral to community continence services

Contents:

      • Stress incontinence
      • Urge incontinence
      • Overflow incontinence
      • Post-micturition dribble
      • General advice for patients

Stress incontinence:

      • Accidental leakage when coughs, laughs, sneezes or bends down
      • The following predispose to SI:
        • Pregnancy
        • Childbirth
        • Being overweight
        • Hysterectomy
        • Smoking/ Chronic cough
        • Pelvic fracture
      •  Helpful lifestyle changes:
        • Stop smoking
        • Losing weight
        • Avoid caffeinated beverages
        • Wearing incontinence pads
      •  Pelvic floor exercises
        • Pretend you are trying to stop the flow of urine
        • Hold the squeeze for 10 seconds, then rest for 10 seconds
        • Do 3-4 sets daily
      •  Vaginal cones
      •  Surgery

Urge incontinence:

      • Happens when the urge to pass urine is so strong that urine starts to leak before reaching the toilet
      • Commonly occurs together with stress incontinence
      • Patients often find urge incontinence more bothersome than stress incontinence
      • Bladder training aims to teach the bladder to hold on a little longer – needs to be continued for at least 6 weeks – gradually increase the time between voids
        • Includes timed voiding
      • Try anti-cholinergics if not contra-indicated – oxybutynin, tolterodine, solifenacin, trospium
        • Warn patients that side-effects include dry mouth, blurred vision & constipation
      • If anti-cholinergics are contra-indicated or ineffective, try Mirabegron
      • Hormone replacement therapy may be useful in women after the menopause
      • If all these options do not work, patients may benefit from intravesical botox
        • This carries a significant risk of patients needing to perform self-catheterization (approx 15%)

Overflow incontinence:

      • Tends to happen when the bladder does not empty completely
      • More common in men
      • Patients should avoid constipation
      • Consider referral to urology

Post-micturition dribble:

      • Usually no cause – need to exclude urethral stricture or urethral diverticulum

General advice for patients:

      • Avoid constipation
      • Eat plenty of fresh fruit, vegetable & cereals
      • Drink at least 6-8 glasses of water a day
      • Avoid tea, coffee, cola & other caffeinated drinks
      • Take regular exercise
      • Wear clothes that are easy to manage
      • Avoid drinking too much fluid within 2-3 hours of going to bed at night
      • Avoid strenuous exertion/ heavy lifting
      • Avoid alcohol

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Incontinence – Male

Definition:

Leakage of urine; depends upon type

Advice:

Isolated male incontinence should be referred directly. If associated with other symptoms, refer to male lower urinary tract symptoms

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Infertility

Definition:

Does not usually require urological referral

Advice:

Most male factor infertility is best managed by review of the affected couple in an infertility clinic

Contents:

      • Initial assessment in primary care
      • Semen analysis
      • General advice for reproductive health
      • Azoospermia with normal FSH
      • Azoospermia with raised FSH
      • Other hormonal abnormalities

Initial assessment in primary care:

      • Full history
        • Childhood illnesses – post pubertal mumps, testicular trauma, torsion
        • Occupational exposure
        • Environmental toxins
      • Drug history
        • Cancer chemotherapy
        • Anabolic steroids
        • Cimetidine & spironolactone
        • Sulfasalazine & notrofurantoin amy affect sperm motility
      • Full physical examination including genitalia & DRE
      • 2 sperm counts
        • delivered within 2 hours of masturbation
        • in the plastic container provided. Do not use glass as the silica in glass tends to destroy sperms
        • after at least 2 days’ abstention from intercourse
      • FSH, LH, prolactin

Semen analysis

      • http://www.who.int/reproductivehealth/publications/infertility/9789241547789/en/

 

General advice for reproductive health:

      • Multivitamins may assist with sperm function
      • 1 gram a day of vitamin C may help
      • Try to get 6-8 hours sleep at night
      • Stop smoking
      • Eat a balanced diet
      • Exercise regularly
      • Decrease caffeine intake – either 2 cups of coffee a day or no more than 2 cans of caffeinated beverages
      • Limit alcohol
      • Decrease stress in life as much as possible
      • Avoid gonadotoxins
      • Avoid wearing excessively tight underwear
      • Minimize excessive heat from sitting in hot tubs, saunas or spas

 

Azoospermia with normal FSH:

      • Vasography & testicular biopsy are no longer indicated
      • Referral to an infertility clinic is best

 

Azoospermia with raised FSH:

      • Indicates primary testicular failure
      • No treatment available
      • Urological referral not indicated
      • Consider adoption or donor insemination

 

Other hormonal abnormalities:

      • If there is evidence of hypogonadism, raised prolactin, or other hormone abnormality, refer to endocrinology

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Loin pain

Definition:

Pain lateralized to loin/ flank may indicate renal problems

Advice:

Only refer if demonstrable urological abnormality

Contents:

      • Investigations
      • Clinical information

Investigations:

If renal colic is suspected, please request a non-contrast CT scan, which is the investigation of choice. An ultrasound is not helpful in renal colic.

Clinical Information:

A patient who has a normal ultrasound and a normal CT scan is unlikely to have renal colic. Please consider whether a urological referral is therefore appropriate in this group of patients.

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Male Lower urinary tract symptoms (LUTs)

Definition:

Bothersome symptoms in a male

Advice:

Please give men conservative advice & drug management in primary care

Contents:

      • Classification of male LUTs
      • Advice to GPs

Classification of male LUTs:

      • Storage symptoms –related to bladder’s function of storing urine
        • Include urgency, frequency, nocturia & urge incontinence
      • Voiding symptoms, including post-micturition symptoms
        • Hesitancy, weak force of stream, intermittent stream, straining, terminal dribbling, sense of incomplete dribbling

Advice to GPs:

      • Exclude serious illness
      • Exclude possibility of prostate cancer
        • If you have done a PSA, please send the result & date it was done
      • Please provide information about treatments that you have already trued

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Neurogenic bladder

Definition:

Abnormal bladder function due to damage to part of the nervous system

Advice:

Requires urological referral

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Paraphimosis

Definition:

Foreskin becomes trapped behind glans penis & cannot be reduced

Advice:

Urological emergency unless foreskin can be manually manipulated

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Penile fracture

Definition:

Rupture of 1 or both tunica albuginea caused by rapid blunt force. Often associated with a popping or cracking sound, pain & immediate flaccidity

Advice:

Urological emergency

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Peyronie’s disease

Definition:

Condition affecting penis resulting in curvature, pain or palpable mass

Advice:

May require referral if pain severe or affects penetration

Contents:

      • Clinical information
      • Treatment
      • When to refer

Clinical information:

      • Affects approximately 4% men over 40 years of age
      • Most men are asymptomatic
      • Disease has 2 phases:
        • Acute – lasts 6-18 months – disease may progress during this stage
        • Chronic – deformity remains stable

Treatment:

      • No effective medical treatment
      • No benfit from ESWL
      • Tamoxifen 20mg BD for 6 weeks may be useful in the early painful stage
      • In 3-13% men, there is spontaneous resolution & treatment is not required
      • Disease progression is noted in 30-50%
      • Disease stabilizes in 47-67%
      • Surgery is only indicated once the disease has been stable for at least 6 months
        • if degree of curvature is < 60 degrees, then penile shortening may be acceptable – Nesbitt’s or plication may be used
        • if degree of curvature is > 60 degrees or there is significant penile shortening, then a grafting procedure may be used
        • if erectile dysfunction is present & not responding to treatment, then consider penile prosthesis

When to refer:

      • If deformity prevent penetration
      • Patient willing to consider surgery

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Phimosis

Definition:

Inability to retract foreskin

Advice:

Refer if non-retractile or recurrent infections of foreskin

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Pneumaturia

Definition:

Passage of gas mixed with urine

Advice:

May be indicative of a colo-vesical fistula & urological referral may not be appropriate Refer to: Colo-rectal surgeons

Contents:

      • Clinical information

Clinical information:

      • Most commonly due to a colo-vesical fistula, which could be from:
        • Diverticular disease, Crohn’s disease, bowel cancer
      • Rarely due to gas-producing bacterial infection of the urinary tract

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Priapism

Definition:

Persistent, usually painful erection that lasts for more than 4 hours in the absence of sexual stimulation

Advice:

Requires immediate referral

Contents:

      • Idiopathic (low-flow) priapism
      • Stuttering (low-flow) priapism
      • Drug-induced (low-flow) priapism

Idiopathic (low-flow) priapism:

      • Refer as soon as onset of symptoms
      • Delay of > 12 hours can result in permanent loss of erections in all patients
      • May resolve with aspiration
      • If delay in diagnosis, may require penile prosthesis

Stuttering (low-flow) priapism:

      • Characterized by repetitive, transient, painful, self-limiting episodes of priapism
      • Associated with haematological disorders including sickle cell disease/ trait or patients taking medication such as phenothiazines
      • Best managed by vasoconstrictors & cessation of the precipitating drug
      • Prophylactic treatment with beta-blockers, pheylpropanolamine, digoxin and cimetidine has been recommended in this group of patients

Drug-induced (low-flow) priapism:

      • Usually due to self-administered injections for erectile dysfunction
      • Requires urgent decompression to preserve potency

Traumatic (high-flow) priapism:

      • Usually due to a traumatic fistula
      • Best treated by selective embolisation of the affected artery
      • Immediate referral is essential

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Prostatitis

Definition:

Infection or inflammation of the prostate

Advice:

Referral only required for acute prostatitis or chronic prostatitis unresponsive to treatment

Contents:

      • Type I (acute prostatitis)
      • Type II (chronic bacterial prostatitis)
      • Granulomatous prostatitis
      • Type IIIa (chronic abacterial prostatitis)
      • Type IIIb (chronic pelvic pain)
      • Type IV (incidental prostatitis)
      • Clinical information

Type I (acute prostatitis):

      • Associated with acute pain & severe systemic symptoms
      • Requires emergency admission for intravenous antibiotics
      • If patient requires a catheter, this should be a suprapubic catheter
      • If a prostatic abscess develops, drainage requires transurethral prostatic incision

Type II (chronic bacterial prostatitis):

      • can present as recurrent UTIs
      • give a 2 month course of antibiotics with good prostatic penetration & NSAIDs
        • Ofloxacin
        • Ciprofloxacin
      • common to get relapse (approx 70%)
      • does no require referral unless patient patient is getting recurrent UTIs
      • may benefit from an alpha-blocker to relax the prostate

Granulomatous prostatitis:

      • rare
      • associated with raised PSA
      • 6-week course of Augmentin is required

Type IIIa (chronic abacterial prostatitis):

      • Treat patients only if symptomatic
        • 6-8 week course of NSAIDs
        • may also require an alpha-blocker or muscle relaxant
      • there is no cure
      • aim of treatment is relief of symptoms
      • it may be more appropriate to refer to the Chronic Pain clinic

Type IIIb (chronic pelvic pain):

      • as for Type IIIa

Type IV (incidental prostatitis):

      • usually found at the time of prostate biopsies
      • treatment should only be instigated by the urology department

Clinical information:

      • patient may find that their symptoms are worse when under stress
      • spicy foods, alcohol & coffee may aggravate symptoms

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PSA

Definition:

Prostate specific antigen

Advice:

Age reference values are available

Contents:

      • When to measure PSA
      • When NOT to measure PSA
      • Age reference values

When to measure PSA:

      • routine measurement is not indicated as PSA is not a screening tool
      • please discuss with patient before checking PSA as this should be done after consent
      • patients under 75 years with LUTs
      • suspected prostate cancer in the presence of bony abnormalities, enlarged lymph nodes, or other evidence of metastatic disease
      • abnormal DRE
      • strong family history of prostate cancer (affected father, uncle or brother)
      • patients of Afro-Caribbean descent
      • for follow-up of known prostate cancer patients

When NOT to measure PSA:

      • routinely in patients with haematuria
      • when the patient has an active UTI
      • within 3 months of a UTI
      • in patients with proven prostatitis
      • in patients with a life-expectancy of < 10 years

Age reference values (units µg/L)

      • up to 49 years: 0.1 – 2.5
      • 50-59 years: 0.1 – 3.5
      • 60-69 years: 0.1 – 4.5
      • 70-79 years: 0.1 – 6.5
      • > 80 years: up to 10

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Renal calculi

Definition:

Stones in kidneys, bladder or ureters

Advice:

referral not indicated in asymptomatic patients with incidental stones

Contents:

      • Basic metabolic investigations
      • Additional metabolic tests
      • Imaging
      • Preventing stones
      • ESWL

Basic metabolic investigations:

      • Serum electrolytes
      • Bone function tests
      • Plasma urate
      • Stone analysis (if stone collected)

Additional metabolic tests:

Required in the following groups of patients:

      • < 40 years of age
      • Multiple stones
      • Recurrent stone disease within 5 years of previous stone
      • Strong family history of stone disease

Tests required include:

      • 24 hour urine collection in acid bottle for calcium, oxalate, phosphate & citrate
      • 24 hour urine collection in plain bottle for urate & sodium
      • Early morning urinary pH

Imaging:

      • Non-contrast CT scan is the gold standard (NCCT)
      • Ultrasound is not appropriate as it is not sensitive for ureteric stones

Preventing stones:

      • Aim to drink 2-3 litres (4-6 pints) of fluid a day
      • Moderate consumption of tea, coffee & alcohol
      • Restrict protein intake & avoid large portions of meat, fish, eggs, cheese & milk
      • Avoid high salt intake – aim for < 0.4g of sodium per serving
      • Avoid Vitamin D supplements as they increase calcium absorption
      • Avoid vitamin C supplements as they can increase the urinary excretion of oxalate

ESWL:

      • Used to treat majority of renal calculi
      • Large renal stones may require PCNL or nephrectomy
      • Patients may have a stent inserted prior to ESWL for large stones
      • There is no indication to treat stent symptoms with antibiotics – NSAIDs may help

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Retention of urine

Definition:

Inability to void urine

Advice:

Immediate referral may be indicated

Contents:

      • Classification
      • When to refer
      • Trial Without Catheter (TWOC)

Classification:

      • Acute retention- painful & recent onset. Residual volume tends to be < 1 litre
      • Chronic retention – may be painless & tends to be insidious in onset. Large residual volumes.
      • Clot retention – inability to void due to bladder clots causing a blockage

When to refer:

      • Patients with acute retention do not necessarily require admission. They can be catheterized in the community & referred directly for TWOC
        • Please start these patients on an alpha-blocker prior to TWOC
      • Patients with chronic retention may require admission as they undergo a period of diuresis & may have decompression haematuria
      • Patients with clot retention require immediate referral for insertion of a 3-way catheter & irrigation/ bladder washouts

TWOC:

      • Nurses can usually undertake a TWOC directly

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Sterile pyuria

Definition:

Presence of white cells in a urine sample

Advice:

Requires urological referral for further investigation

Contents: 

      • Possible causes
      • Clinical information

Possible causes:

      • Usually caused by incompletely treated urinary infection
      • May be within 2 weeks of UTI
      • Urinary tract calculi
      • Urinary tract neoplasm
      • Genitor-urinary tuberculosis – please do 3 early morning urine samples

Clinical information:

      • Refer to urology if sterile pyuria noted on 2 separate MSUs

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Torsion

Definition:

Can be torsion of testis or testicular appendage

Advice:

Immediate referral indicated

Contents:

Torsion of the testis

Torsion of the testicular appendage

Torsion of the testis

  • Urological emergency
  • No place for ultrasound
  • Requires urgent surgical exploration within 4 hours of onset of pain
  • 12 hour delay in exploration is associated with 50% rate of testicular loss
  • 24 hour delay in exploration results on infarction &n non-viable testes in almost all cases

 

Torsion of testicular appendage

  • Less urgent than testicular torsion
  • Symptoms can be difficult to distinguish from testicular torsion
  • Requires emergency admission
  • If a confident diagnosis can be made, then can be managed conservatively
  • Pain tends to resolve within 1 week, but may persist for several weeks
  • Necrotic tissue tends to reabsorb over time

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Trauma to urinary tract

Definition:

Injury can be to any part of the urinary tract

Advice:

Immediate referral in indicated

Contents:

Injury to kidney, bladder or urethra

Injury to kidney, bladder or urethra

Coital injuries

Scrotal injuries

 

Injury to kidney, bladder or urethra:

  • Usually results in haematuria
  • There may be associated local bruising
  • Please do not insert urethral catheter if there is urethral bleeding

 

Injury to kidney, bladder or urethra:

  • Can be bleeding from a frenular tear
  • May be due to foreskin caught in a zipper

 

Coital injuries:

  • Penile fracture should be referred as an emergency

Scrotal injuries:

  • Should be assessed with ultrasound
  • Urgent referral is required of there is an open wound or closed injury to the testis

 

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TWOC

Definition:

Trial without catheter

Advice:

Patients may not need to see a urologist first

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Ureteric calculi

Definition:

Calculi in ureters

Advice:

Referral indicated for all ureteric calculi > 5mm in diameter & refer as an emergency for uncontrolled symptoms

Contents:

      • Natural history
      • Indications for urological intervention
      • Treatment options

Natural history:

      • Approximately 60% of ureteral stones will pass spontaneously within 4 weeks
      • For smaller stones < 5mm diameter, approximately 90% will spontaneously pass
      • Most patients will have haematuria
      • Unenhanced CT scan (NCCT) is the investigation of choice
      • There is no place for an ultrasound scan

Indications for urological intervention:

      • An obstructed & infected kidney requires urgent decompression
      • Uncontrolled pain may require insertion of a ureteric stent or removal of the stone

Treatment options:

      • Ureteroscopy for calculi in the mid/ lower ureter
      • In situ lithotripsy for stones in the upper third of the ureter
      • Push-bang treatment requires endoscopic dislodgment of the stone, which is pushed from the ureter into the kidney & subsequent ESWL
      • PCNL – percutaneous nephrolithotomy
      • Open nephrolithotomy – rare
      • Nephrectomy for stones in non-functioning kidney

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Urethral discharge

Definition:

Discharge from the urethra

Advice:

Does not require urological referral, but may required a referral to GUM

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Varicocoele

Definition:

Abnormal dilatations or enlargements of the veins within the scrotum

Advice:

Referral is indicated for symptoms or for sub-fertility

Contents:

      • Clinical information
      • Indications for treatment
      • Treatment options

Clinical information:

      • 98% occur on the left side
        • Sudden onset on this side should raise suspicion of left renal tumour
      • If occurs on the right side – suspect retroperitoneal tumour
      • Asymptomatic varicocoeles do no require referral
      • 20% of infertile men have a varicocoele that may be implicated in their infertility

Indications for treatment:

      • Significant discomfort
      • Cosmesis with a large varicocoele
      • Sub-fertility & varicocoele

Treatment options:

      • Surgical ligation through the groin
      • Laparoscopic ligation
      • Embolization

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Vasectomy

Definition:

Minor surgical procedure to cut the vas deferens & interrupt sperm transport

Advice for patients:

      • Avoid strenuous exercise or sexual activity for 1 week
      • Patients can safely have a bath/ shower after vasectomy
      • Minimize swelling by use of ice packs on the scrotum & tight underwear (scrotal support)
      • Resume sexual activity after approximately 1 week
      • Most men can return to work within 1-2 days

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Vasectomy reversal

Definition:

Procedure to restore fertility by reconnecting the cut ends of the vas deferens

Advice:

Not available on NHS. Requires private referral

Contents:

      • Clinical information

Clinical information:

      • Requires general anaesthetic
      • Not performed on NHS unless severe symptoms following vasectomy
      • Success rates are up to 55% if reversal carried out within 10 years of vasectomy
      • Success rates fall to approximately 25% if performed more than 10 years after original vasectomy
      • Success rate defined as delivering a baby after vasectomy reversal

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