GP GUIDELINES

These notes have been compiled for use in General Practice, but
might also be of use to others who have patients under care with
coincidental Urological problems. Correspondence to:
edu@bui.ac.uk
Contributors: RCL Feneley, JC Gingell, P Abrams, JD Frank, DA
Gillatt, GNA Sibley, A Timoney, DA Dickerson an A !inc"li##e
$%itor&
P! version "#$%&' for printing.
"P()*+) ,-T) the Guidelines are being updated and the P! version ma. differ
to those below'
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CONTENTS
Urinary Tract
Stones
Catheter Care Paediatric Section
Adult Urinary
Tract Infections
Haematuria
asectomy
!e"ersal
Urinary
Incontinence
#eni$n
Enlar$ement %
Carcinoma of
Prostate
Infertility
Painful Scrotum Scrotal S&ellin$s Im'otence
U!INA!( T!ACT STONES
!ENAL COLIC
ANALGESIA
I))U!OG!A*
SC!EENING INESTIGATIONS
T!EAT*ENT OPTIONS +O! ALL U!INA!( T!ACT STONES
!ENAL COLIC
Suspected Renal Colic - Advice Summary
We will see and admit if necessary any acute case of renal
colic.
Alternatively, if home management is decided upon:
Analgesia : Pethidine I.M. or Diclofenac oral or suppository
(see contraindications
M!"
I#" within $% hours if possi&le
'efer urgently &y telephone if o&structed or &y letter if not
o&structed &ut
stone fails to pass.
'efer urgently &y telephone any patient with persistent pain,
fever or loin
tenderness.
Patients with urinar. tract stones commonl. present with renal colic
and the ma1orit. will pass the stone spontaneousl.. This depends on
the si2e and the position of the stone, but most causing colic are
under 3 mm in diameter.
Patients presenting with apparent renal colic need confirmation of
the diagnosis.
4+U for haematuria and culture.
Plain 56ra. "&U7' followed b. 89U as soon as possible,
even if a stone has
passed "there ma. be more and signs of obstruction
ma. show'.
8f .ou are managing the patient at home, persistent
pain after $: hours, loin tenderness or fever indicate the
need for urgent referral.
*,*(G)+8*
The patient with renal colic re;uires urgent analgesia. The
traditional treatment for the pain has been Pethidine <== mg b.
intramuscular in1ection. -ral Pethidine tablets are not usuall.
ade;uate but iclofenac #3 mg orall., or as a <== mg suppositor.,
can be a useful alternative. ,ote, however, that renal failure has
been associated with the use of this drug. Those particularl. at risk
are patients with underl.ing renal disease, cirrhosis, congestive
heart failure, the elderl., those taking diuretics and those with
significant cardio vascular disease. 8t is contraindicated in patients
with asthma and those taking *C) inhibitors.
-ur recommendation, therefore, is to confine the use of iclofenac
to fit patients, under 33 .ears of age who are not on diuretics and
to prescribe no more than 3 doses without further investigation.
8,T0*9),-U+ U0-G0*4
8f .ou have managed to arrange 56ra.s, the urologist needs to see
the films "not 1ust a report' with the patient, if referred. +ome
hospitals are slow to part with films, so, to avoid unnecessar.
repeat 56ra.s, it is most helpful to arrange them at the same
hospital where the patient is likel. to attend if a consultation seems
indicated.
+C0)),8,G 8,9)+T8G*T8-,+
The stone should alwa.s be sent for chemical anal.sis if possible>
the ma1orit. contain calcium o?alate, but it is important to identif.
the uric acid or c.stine stones because medical treatment is
available "and the. do not show on plain 56ra.s'. Please remember
to tell the patient to pass urine into a receptacle.
The outline screening tests should include the following laborator.
investigations :6
4+U, full blood picture, urea, creatinine, sodium, potassium,
chloride, bicarbonate, uric acid, calcium and phosphate.
T0)*T4),T -PT8-,+
!or stones that do not pass spontaneousl..
There are four methods of managing upper urinar. tract stones,
either alone or in combination.
<. )?tracorporeal +hock @ave (ithotrips. ")+@('
$. Percutaneous ,ephrolithotom. "PC,('
%. Ureteroscop.
:. -pen +urger.
%S'L
The (ithotriptor at +outhmead is a second generation machine
which can shatter most renal and ureteric stones, but, more than
one treatment ma. be re;uired. 4ost patients can be treated
without admission under mild sedoanalgesia. The fragments pass
out in the urine, usuall. with minimal discomfort, although there
ma. be transient haematuria and some patients e?perience slight
skin bruising where the shock wave enters. *bout <3A of patients
e?perience renal colic, half of whom ma. need readmission if the
ureter is obstructed. 8f a renal stone is more than $ cm in diameter
a ureteric stent is placed to prevent stone debris causing
obstruction. +tents are also used as a preliminar. in some patients
whose upper ureters are initiall. obstructed b. stone. These stents
should be removed within B weeks of insertion "stone formers can
form stones on them'.
PCNL
Percutaneous renal surger. is performed to remove some renal
stones if the. fail to fragment with )+@( or to debulk the ver. large
ones. 8t usuall. entails hospitalisation for a period of : 6 C da.s.
(R%T%R)SC)P*
The new generation of ureteroscopes are of a fine diameter which
has greatl. facilitated
their passage up a ureter. Ureteric stones can be visualised and
removed with a basket or fragmented using lithotriptor probes.
)P%N S(RG%R*
There is still a place for the classical operative approach for stones,
but the indications are now becoming rare.
+LADD%R ST)N%S
4a. be associated with bladder outlet obstruction.
Particularl. vulnerable group 6 immobile patients with long6term
indwelling catheters. Those with persistent irritable bladder
s.mptoms need a &U7 56ra..
Treatment 6 )ndoscopic "a few need open surger.'.
AFT%R CAR%,ST)N% PR%-%NT.)N "apart from specific treatment of
underl.ing causes'.
D&eep the urine dilute, ie., avoid producing deep coloured urine
throughout the $: hours, even if .ou have to get up once at night
to empt. .our bladder.D
0eduction of dietar. calcium was thought to be helpful in preventing
stones but e?cess of calcium in the gut combines with o?alate and is
not absorbed. 8f calcium intake is reduced, more o?alate is
absorbed and the resulting h.pero?aluria "particularl. during the
night hours' carries a greater risk of stone formation and
h.percalciuria.
ADULT U!INA!( T!ACT IN+ECTIONS
U08,) 48C0-+C-P/ E CU(TU0)
U08,) C/T-(-G/
84*G8,G
708)! ,-T)+ -, P*0T8CU(*0 C*+)+
Advice Summary
Although urinary tract infections are common in women, they are not
commonly associated with significant underlying pathology, so
investigation can &e selective depending on severity of infection, the
types of organisms cultured, persistence or recurrence, as well as
localising symptoms and signs.
Males with ".(.I. are much more li)ely to have underlying pathology
and should &e investigated
After history and e*amination all the initial investigations can &e
accomplished on or &y arrangement &y the practice.
(he first priority is to confirm the infection.
4+U
!or microscop. and culture obtained before antibiotic treatment 6
the most important but sometimes the most inconvenient to
arrange from the Practice. The specimen must be a clean catch "or
catheter specimen if there is difficult. in females' F and must be
fresh on arrival at the laborator. "or refrigerated, overnight at
most, until it can be delivered'. The (ab ma. indicate a suspicion of
contamination, rather than true infection on a report if there are a
few cells or the organisms are of doubtful significance. The
commonest organism cultured is ).Coli, other organisms are more
likel. to be associated with an underl.ing urinar. tract abnormalit.,
hospital ac;uired infection or an indwelling catheter.
* further 4+U one week after treatment is also important.
Persistent, rather than recurrent, infection is common with the
presence of urinar. tract abnormalities and is not alwa.s
s.mptomatic.
@e would not recommend routine use of broad spectrum antibiotics
unless indicated b. 4.+.U. culture.
U08,) C/T-(-G/ 8n cases with associated haematuria.
C.tolog. ma. be difficult to interpret until the infection is eliminated
"as it is the presence of urinar. calculi or irradiation c.stitis'.
Persistent c.stitis s.mptoms with microscopic haematuria, in spite
of ade;uate treatment for an. infection present "refer earl.', ma.
indicate chronic interstitial c.stitis or transitional carcinoma in situ
"D4alignant C.stitisD 6 c.tolog. usuall. malignant'.
U(T0*+-U, -! TG) U08,*0/ T0*CT *, &U7 560*/
The combination of these two non6intrusive investigations shows up
man. abnormalities, including man. in the renal parench.ma,
h.dronephrosis, most stones, residual bladder urine after voiding
etc. 8f the. are normal in the absence of haematuria or loin pain,
then 89U and other imaging techni;ues are rarel. indicated.
!7C, U0)* E C0)*T8,8,) "on suspicion of reduced renal function'
F +ee Para 3 6 +ection on 8ncontinence
#!IE+ NOTES ON PA!TICULA! CASES
Asym'tomatic ,acteriuria 6 all need investigation "although this
is limited in pregnanc. when treatment to avoid the common se;uel
of p.elonephritis is necessar. 6 refer to *ntenatal Clinic if need be.
Sterile 'yuria 6 "not presenting as urethritis' 6 think of T7 and
other organisms failing to culture on normal media as well as
interstitial c.stitis.
-Prostatitis- 6 covers a number of s.ndromes characterised b.
var.ing degrees of perineal and pelvic pain, malaise, painful voiding
of urine, poor stream and fre;uenc.. 8nfection with common entero6
bacteria as for UT8s is easil. demonstrated in some whilst in others
the cause is obscure and treatment difficult. +.mptoms are not
alwa.s clearl. defined, so microbiological findings are all important
as a guide to classification and management.
8n all cases before treatment starts, and as far as the patient in pain
will allow, the following should be obtained 6 4+U, e?pressed
prostatic secretions ")P+' from urethra or initial urine after prostatic
massage.
Acute ,acterial 'rostatitis 6 4+U and )P+ "if obtained' both
cultures positive. "7lood cultures ma. also be positive'.
Can be a ver. severe illness with occasional septicaemia, prostatic
abscess and acute retention. +evere cases need prompt admission.
*ll cases need treatment for B weeks with an appropriate antibiotic
after initial empirical treatment> Trimethoprim is suitable if the
organisms are sensitive. Ciproflo?acin is an alternative in resistant
cases.
Chronic ,acterial 'rostatitis 6 4+U culture usuall. negative. )P+
leucoc.tosis, culture usuall. positive.
+i? week treatment as above. 0elapse needs further investigation
followed b. more prolonged use of antibiotic or prostatic resection
"especiall. if prostatic calculi are present'.
-Non.,acterial- 'rostatitis 6 4+U DsterileD on normal media.
Therefore, some cases infected with a range of fastidious organisms
have been misfiled under this heading. Chlam.dia and urea plasma
have been implicated, for e?ample, although few respond to
Tetrac.cline treatment. Gonorrhoea and T7 can also be missed if
not specificall. looked for 6 microbiological help needed at the
outset and referral to +T Clinic, if appropriate. +ome with
completel. negative findings, apart from )P+ leucoc.tosis, ma.
benefit from prostatic resection. The possible role of viruses has not
been defined.
Prostadynia 6 4+U no significant cells and sterile on culture.
+e?ual d.sfunction ma. be an additional s.mptom to those listed
above. Careful investigation of bladder outlet function and
ps.chological factors needed with treatment according to the
findings.
THE PAIN+UL SC!OTU*
)pidid.mitis 6 +i? weeks antibiotic treatment recommended. 8f it
does not show signs of progressive resolution, think of Chlam.dia
and T7 "but do not necessaril. e?pect to find organisms in the
urine'.
Testicular tumour 6 also a possibilit.. 0efer for ultrasound and
consultation. *lso, please let us know if .ou have patients with
post6operative epidid.mitis "TU0s etc'.
+perm granuloma 6 after vasectom. can mas;uerade as chronic
epidid.mitis. Ultrasound and refer.
*cute orchitis 6 4ostl. virus infection "usuall. mumps'. 4umps
orchitis occurs onl. after pubert. and most are unilateral. Testicular
atroph. ma. follow 6 advise referral and ultrasound "steroids rather
than testicular decompression ma. reduce the chance of atroph.'.
,ote on testicular torsion 6 included here because differentiation
from epidid.mitis and orchitis is not alwa.s eas., especiall. when
the patient presents a little while after the event when local signs
appear inflammator.. Gistor. is important and previous episodes of
sudden pain with rapid resolution are not are not uncommon in
testicular torsion. 8t can occur at an. age, although <= 6 $= .ears is
the commonest. 8t ma. also occur at an. time including during
sleep. 8f there is a possibilit. of torsion, send the patient to the
nearest * E ) epartment b. an. means immediatel. and Hphone
the urolog. or General +urgical !irm on take at the same time.
Torsion of the appendi? testis "ma. be a visibleIpalpable bluish
lump at the upper pole in the earl. stages' 6 same applies, we
e?plore them immediatel..
Lon$term ind&ellin$ catheter users and those &ith urinary
di"ersions 6 will all have organisms in the urine. Treat onl. if
patient has s.mptoms.
!ecurrent 'ro"en infection &ith ,ladder outlet o,struction)
These patients usuall. re;uire active treatment such as TU0P or a
urethral dilatation in an elderl. woman. +hould urinar. infections
persist despite eliminating residual urine as a possible cause, then it
ma. be necessar. to institute longterm low dose antibiotics.
)?perience has shown that it is best to rotate these low dose
antibiotics, such as *mpicillin, ,itrofurantoin and Trimethoprim, on
a monthl. basis. 8f there is a persistent residual urine, and the
outflow tract resistance has been lowered as far as possible, then
intermittent self6catheterisation is a ver. effective wa. of ensuring
the abolition of the residual urine and effective control of the
s.mptoms.
Urethral syndrome) The s.mptoms of c.stitis without 4+U
abnormalities in se?uall. active women is relativel. common and
often termed Durethral s.ndrome.D * fre;uenc. volume chart will
provide one ob1ective measure of the s.mptoms. General advice,
such as the self6help advice offered b. *ngela &ilmartinHs book
DUnderstanding C.stitisD "available from most booksellers', should
be the first line of management. Patients with persistent s.mptoms
ma. be referred for consideration of c.stoscop. and urethral
dilatation which helps up to :=A of women.
+re/uently recurrent cystitis in youn$er &omen with otherwise
negative investigations. @e recommend long term "si? months or
more' low dose antibiotic. 8n post menopausal women, not on G0T,
check also for vaginitis which ma. respond to topical oestrogen
cream application "without an applicator'.
THE *ANAGE*ENT O+ U!INA!( T!ACT IN+ECTIONS IN
ADULTS
U!INA!( INCONTINENCE

!0)JU),C/ *, 9-(U4) CG*0T
486+T0)*4 -0 C*TG)T)0 +P)C84), -! U08,) "C()*, C*TCG'
P(*8, U08,*0/ T0*CT 560*/ "&U7'-0 U(T0*+-U, +C*,
C-,T8,),C) *98+-0/ +)098C)
7(*)0 T0*8,8,G
C*TG)T)0 C*0)
!0)JU),C/ *, 9-(U4) CG*0T
The initial assessment of the patient should include a fre;uenc. and
volume chart> the patient records the time and the volume of urine
passed, together with an. episodes of leakage that ma. occur over
a period of # da.s. The number of incontinence pads used per da.
should also be recorded. uring a $: hour c.cle, the normal
individual passes urine between : and C times, with ma?imum
volumes between %== 6 B== ml and a total output of <$== 6 <C==
ml.
The fre;uent passage of small volumes of urine with urinar.
incontinence suggests either a bladder of small capacit. or one that
fails to empt. completel.. 0educed capacit. ma. be due to habit
"possibl. from fear of incontinence', to h.persensitivit. from
infection or stones, to an unstable bladder from detrusor
overactivit. or to a contracted bladder from chronic inflammator.
changes or carcinoma.
The bladder that fails to empt. completel. ma. be palpable if it is
holding more than %== ml, or it ma. be demonstrable on a plain 56
ra. or an ultrasound scan.
Urinar. leakage with a normal bladder capacit. suggests sphincter
weakness as in stress incontinence, but urod.namic investigations
ma. be necessar. to confirm this. Urod.namic studies have a vital
role in differentiating the various t.pes of incontinence, namel.
stress, urge, overflow and refle? or neuropathic incontinence.
-n the clinical e?amination, the option of taking a specimen of urine
using a fine <$ or <: !G disposable catheter should be given
consideration when e?amining female patients. Patients
handicapped b. age, immobilit., obesit. etc cannot easil. provide
an 4+U without a high risk of contamination and, in such cases, the
report of bacteriuria with or without p.uria can be misleading.
)?amination of the urine is such a routine test, but the path report
does need 1udicious interpretation.
Patients with urinar. incontinence and a c.stocoele usuall. re;uire
video6urod.namic studies before the correct course of management
can be planned. Those with uterine prolapse are usuall. directed to
the g.naecological clinic, but man. elderl. women have evidence of
atrophic vaginitis which responds well to local oestrogen creams.
These are best applied digitall. rather than through a plastic
introducer which can make them sore.
-bese patients should be advised about strict dieting. This is a
therapeutic e?ercise as well as an essential preoperative re;uisite.
+!E0UENC(1OLU*E CHA!T . as used at Southmead
Please complete the confidential form as accuratel. as possible.
Please note the time .ou pass .our water and the volume passed.
*n. measuring 1ug will do for this purpose. -bviousl. when .ou are
at work it ma. be inconvenient to measure the volume> in this case,
record onl. the time. Gowever, at other times please tr. to record
both.
8f .ou wet .ourself at an. time, record the time and underneath
write the letter D@D.
a.6time means when .ou are up> night6time means when .ou are
in bed.
*n e?ample is provided below to help .ou :
E2am'le
*/
TimeIvolume"mls'
*/6T84)
,8GGT6T84)
,umber
of pads
used in
$: hour
period
<
#am I $== <pm I
66F Bpm I :==
<<pm I %==
"Fat work,
couldnKt measure
volume'
%am I $== Bam
.................@....
..
$ .. .. ..
%
.. ..
..

,*4) LLLLLLLLLLLLLLLLLLLLLLLLLLLLL ate of *ppointment
LLLLLLLLL
*/ Time I volume "mls'
DA(.TI*E
NIGHT.TI*E ,umber of
pads used in
$: hour
period
< .. .. ..
$ .. .. ..
% .. .. ..
: .. .. ..
3 .. .. ..
B .. .. ..
# .. .. ..
*9)0*G) *8(/ !(U8 8,T*&) "in cups' M
LLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLL
AN ALTE!NATIE +!E0UENC( OLU*E CHA!T
<. )ach time .ou empt. .our bladder measure the volume in mls
"millilitres' and write it in one of the hourl. bo?es "there is room to
write several volumes in each bo? if necessar.'. /ou do not need to
write the e?act times. 8f .ou leak urine, write a @ in the bo?.
$. Please mark the time .ou $o to ,ed each night and $et u' for
the da. with a line across the space.
%. 0ecord for -,) @))& prior to .our appointment.
:. /our chart that .ou bring to the clinic should look similar to the
one illustrated below. 8t has a da. filled in as an e?ample.
3. /ou do not need to write down drinks unless the doctor has
re;uested this.
P-+T648CTU08T8-, 0877(8,G -! U08,)
This is a common problem that causes distress to males of all age
groups, thought to be related to a failure of the bulbo6spongiosum
muscle to contract and thus empt. the distal urethra. 8t does not
indicate a prostatic disorder and does not, b. itself, re;uire referral.
+ome patients can be helped simpl. b. showing them how to
compress the bulb of the urethra in the perineum after voiding.
P(*8, U08,*0/ T0*CT 560*/ -0 U(T0*+-U, )5*48,*T8-,
* plain 56ra. should be performed to e?clude bladder stones> if
taken after micturition the film also provides a rough estimate of
the volume of residual urine from the si2e of the soft tissue bladder
shadow. *n ultrasound scan can give a ;uantitative estimate of the
residual volume of urine and an accurate, non6invasive displa. of
urinar. tract anatom. but, compared to the 8ntravenous Urogram, it
fails to provide an. indication of renal function.

C-,T8,),C) *98+-0/ +)098C)
Patients ma. be referred to this service or, in some Gealth
*uthorities, patients ma. refer themselves for advice on the
practical management of their incontinence. The Continence *dvisor
will assess the patient either at home or hospital, and prepare a
report covering the social and ph.sical aspects of the problem. *
wide range of appliances are available and it is important to select
the most appropriate and economic t.pe. +ome patients prefer to
discuss this problem with a well6informed nurse.

* C(8,8C*( T08*( -! 7(*)0 T0*8,8,G
Patients with fre;uenc., urgenc. and urge incontinence form a large
group of regular clinic attenders, and it is well worth introducing a
trial of bladder training. The fre;uenc. and volume chart often
shows that the. can hold reasonable volumes of %== ml urine or
more at times, particularl. during sleep> those who never hold more
than $== ml should be referred to hospital for further investigations.
8n the absence of an. obvious abnormalit. on clinical e?amination
and a negative urine culture, it is worth giving the patient a trial of
bladder training reinforced with an anticholinergic preparation. The
patient should be instructed to pass urine Db. the clockD, starting
with an interval such as ever. two hours which can be managed
without too much difficult.. This interval is graduall. increased to
two or three hours and the patient should keep a chart one da. a
week to monitor progress. * mild sedative at night can be useful
particularl. for those who wake at regular times during sleep to
pass urine. *n anticholinergic preparation such as -?.but.nin $.3
mg can be used to support the training regime with $ 6 B tablets a
da.> Propantheline bromide or 8mipramine are alternative
preparations.
8f there is no response to such a trial, further investigations should
be arranged.
CATHETE! CA!E
(ong6term catheterisation is usuall. considered to be a Dlast resortD
in the management of patients with loss of normal bladder control,
but it should aim to improve their ;ualit. of life not to compromise
it. Catheters introduce a high morbidit. and the occasional
mortalit.. *ll patients with long6term catheters will develop a
chronic bacteriuria> infection arises at the rate of about 3 6 <=A per
da.. @ithin :C hours of introducing a catheter, a biofilm forms on
the surface of the catheter as a fine fibrillar network from deposition
of fibrin, des;uamated urothelial cells and bacteria. The bacteria
produce a gl.cocal.? from long chain pol.saccharides which cause
then to adhere to the surface of the catheter and these sessile
bacteria are protected within the gl.cocal.? from the effect of
antibiotics in contrast to the floating or planktonic bacteria in the
urine. *ntibiotics have a ver. limited place in the treatment of the
chronic bacteriuria associated with long6term catheterisation> the.
are indicated when a patient develops evidence of a s.stemic
infection or when the urine becomes particularl. thick, murk. or
foul6smelling.
The complications of long6term catheterisation include:
C*TG)T)0 7(-C&*G)
7/P*++8,G -0 ()*&*G) *0-U, TG) C*TG)T)0
C*TG)T)0 )5T0U+8-,
+T-,) !-04*T8-,
8,!)CT8-,+:
o )pidid.mitis
o Periurethral abscess
o +epticaemia
The choice between a urethral or suprapubic catheter needs to be
discussed with the patient. *n important factor that influences this
decision is whether or not the patient is se?uall. active> this sub1ect
must be addressed when considering long6term catheterisation for a
disabled person.
Catheter Choice
+tart with a small diameter catheter and in1ect onl. about # 6 <=mls
into the balloon. 0egarding the choice of material, the following is
intended as a guide.
P9C 6 for short term "# 6 <N da.s onl.'
Teflon coated 6 : weeks
+ilicone 6 <$ weeks
DG.drogelD coated 6 <$ weeks
!emales 6 catheter length $$ cm I !G <$ 6 <B I # 6 <=
ml of water in the balloon.
4ales 6 catheter length %: cm I !G <: 6 <C I # 6 <= ml
of water in the balloon.
+tore catheters in a cool, dr., dark environment> the. tend to
perish too rapidl.O
Patients should be urged to maintain a high fluid intake at all times
and to note the colour of the urine. This provides a useful indication
of its concentration, and the aim is to keep it as pale as possible. 8f
the patient is alread. taking a diuretic preparation, it can be helpful
to take this at night when the urine output is normall. reduced. 8t is
advisable to make sure that the patient has a spare catheter of the
correct si2e at home together with a catheter pack, local
anaesthetic I lubricant etc, in the event of the catheter falling out
from deflation of the balloon.
Catheter !emo"al
+ome catheters can be e?tremel. difficult to remove because
occasionall. the balloon fails to deflate. +uction on the s.ringe to
withdraw fluid from the catheter balloon ma. cause the catheter
walls to collapse. *void cutting the catheter tubing but consider
in1ecting $ml of additional water or air into the balloon, as this
sometimes dislodges an. debris obstructing the channel. 8f this
simple manoeuvre fails, refer the patient to the urological
department at the hospital. The balloon can be deflated b.
puncturing it with a needle under radiological control.
Catheter #loc3a$e
Patients with long6term catheters can be placed in two groups,
namel. those who block their catheters and those who do not. The
reason for the high propensit. of some patients to block their
catheters is not understood. The DlifeD of a catheter varies from one
patient to the ne?t and can var. from two weeks to four months>
each patient needs to be assessed individuall. regarding the
fre;uenc. of catheter change. 8t is not 1ustified to use an e?pensive
silicone catheter if the catheter needs to be changed ever. $ 6 :
weeks.
@hen a catheter blocks, it should be removed and replaced b. a
new one, but a note should be made whether the catheter is heavil.
encrusted with debris or not. 8f the catheter becomes blocked at
fre;uent intervals, consider the following points :
+. Gas the patient developed bladder stonesP * plain 56ra.
film "&U7' of the urinar. tract should be performed to
check whether there are an. radio6opa;ue stones. 8f
there is no evidence of stones, e?cessive debris ma. be
a cause and a c.stoscop. should be performed to clear
this.
$. 4ake sure that there is free drainage from the catheter.
The catheter or the tubing can become kinked,
especiall. if inappropriate clothing is worn. -verweight
female patients can occlude a urethral catheter.
%. 8s the patient constipatedP *n impacted sigmoid colon
or rectum can give rise to bladder spasms which
obstruct free drainage of urine. *n enema can be a ver.
useful therapeutic measure under these circumstances.
%. 8f the catheter is heavil. encrusted, send a urine
specimen for culture and prescribe an appropriate
antibiotic after changing the catheter. The culture
willusuall. produce a heterogeneous growth of
organisms.
3. Consider giving a course of allopurinol <== mg tds to
reduce the e?cretion of urates and calcium phosphates.
*cidif.ing the urine with *scorbic *cid Gm < tds is
another measure to consider which might reduce the
phosphatic debris in the bladder.
,. 7ladder washouts are not recommended because the.
cause shedding of the urothelial cells. Gowever, if the
catheter is blocking fre;uentl., regular washouts twice a
week, or occasionall. more often, are worth. of a trial.
Urotainer Chlorhe?idine, +ub.6G or +aline ma. be used.
#y'assin$ or lea3a$e around the catheter 4 E2trusion of the
catheter
7.passing of urine around and spontaneous e?trusion of the
catheter is commonl. e?perienced in patients, particularl. women,
with neurological conditions such as 4ultiple +clerosis. 8t is
tempting to insert a catheter with a larger balloon, but this should
be resisted because it does not prevent the problem and can cause
even greater damage to the urethra. *nticholinergic preparations
ma. be of benefit in these cases, and it is worthwhile tr.ing a
course of Propantheline 7romide or -?.but.nin. 8f the problem
persists, a suprapubic catheter with or without urethral closure
should be considered.
Patients with suprapubic catheters, or their carers should be advised
how to replace the catheter as soon as possible if it should fall out
of the bladder inadvertentl., because the tract can close rapidl.
within < 6 $ hours.
Stone +ormers
+ome patients regularl. form bladder stones. These tend to be
associated with Proteus urinar. tract infections or other urease6
producing bacteria which cause the urine to become alkaline.
Patients who fre;uentl. block their catheters should be suspected of
forming bladder stones. 8f a plain 56ra. of the urinar. tract fails to
reveal an. stones, a c.stoscop. should be performed to e?clude
radiolucent debris.
Infections
Patients with long6term catheters are Dat riskD of infections because
the. carr. a chronic bacteriuria. The infection can manifest itself in
a variet. of wa.s.
E'ididymitis is not an uncommon complication of long6term
catheterisation. 8t usuall. presents as a painful testicular swelling> it
is important to continue antibiotic treatment in these cases for a
period of at least si? weeks to avoid an e?acerbation which often
follows a shorter course.
Periurethral a,scess in male patients can present ver. serious
conse;uences. Ulceration of the urethra can arise at the peno6
scrotal 1unction, where the penis bends ventrall.. The catheter
should be strapped to the lower abdominal wall to prevent the
urethral angulation at this point.
Se'ticaemia can present a serious threat to a debilitated patient
and ma. arise after urethral instrumentation or change of catheter.
* blood culture and 89 antibiotics should be instituted without dela..
Urine Draina$e System
* wide range of products are available to attach to the catheter
which enable the patient to feel comfortable and secure. Patients do
re;uire s.mpathetic, professional advice when the. are first given a
long6term indwelling catheter with details about the choices
available to them regarding the drainage from the catheter.
@henever possible, the. should be given the opportunit. to tr.
different products and to select the one the. consider to be most
appropriate to their needs.
Urine Collection #a$s
Care should be taken to select the urine collection bag that is most
suitable for the individual patient. *ttention should be focused on
the t.pe of taps which are available on the bags for empt.ing and
the ease with which the. can be operated with one or two hands,
avoiding an. finger contamination. The actual capacit. of the bags
varies widel. from %3=ml to $,===ml.
The Lin3 System
The link s.stem refers to the linkage between the bod.6worn bag
during the da. and the night drainage bag. The purpose of the night
bag is to provide undisturbed rest for the user who would otherwise
need to empt. the leg bag at intervals during the night. The link
s.stem is designed to reduce the risks of infection which had
accompanied the previous practice of changing over the leg to the
overnight urinar. drainage s.stem. * variet. of link s.stems are
available and no one t.pe will be suitable for ever. patient in ever.
circumstance.
Sus'ension Systems
+uspension s.stems provide a method of holding a bod.6worn urine
collection bag in place under clothing and offer an alternative to leg
straps. * variet. of designs and si2es are available but most
comprise of an arrangement of straps to secure the suspension
s.stem to the leg. *s an alternative, the patient can tr. a
suspension s.stem that holds the bag on the leg in place, using
either a net sleeve "*;uadr.' or a sleeve from which the bag can be
suspended from the waist.
The ma1orit. of manufacturers of urinar. drainage bags provide
their recommended fi?ation with the drainage bag, but some can be
purchased from the respective compan. as a separate item to be
used with a selection of bags. Choice of suspension s.stems will
depend on the patientHs preference as well as careful assessment of
the patientHs abilities combined with a trial of different t.pes of
suspension s.stems.
Catheter al"es
These devices have not been given an ade;uate test of time as .et.
* catheter valve is connected to the outlet of the catheter allowing
the user to empt. the bladder when convenient and necessar., thus
providing a more discreet alternative to urine drainage bags.
Catheter valves do demand a certain amount of manual de?terit.
and are not suitable for those patients who have lost normal
bladder sensation. These valves are not as .et available on
prescription.
Literature
4anufacturers produce useful handouts and guidelines for patients
and staff on the sub1ect of catheter management, usuall. free of
charge. 8t is well worth obtaining a suppl. of these> each product
varies in its use.
HAE*ATU!IA
In"esti$ations
*SU
U!INE C(TOLOG(
ULT!ASOUND % 5U# 6 !A(
C(STOSCOP(
INT!AENOUS U!OG!A*
Ad"ice Summary
Patients with haematuria should be referred immediatel. to
the Urolog. Clinic. 8t is helpful for an. tests to be re;uested
at the same hospital as referral, so that these are available at
the first clinic visit, but donHt dela. referral whilst awaiting
these results. 4ost hospitals offer a haematuria clinic service
where initial consultation, c.tolog., imaging and fle?ible
c.stoscop. are achieved during one visit b. the patient.
There is a poor correlation between the degree of haematuria and
the severit. of the underl.ing disorder. *ll patients with blood in the
urine, whether macroscopic or persistent microscopic, should
therefore be full. investigated to establish a cause.
*lthough there are man. non malignant causes of haematuria,
painless haematuria is the presenting s.mptom in C3 6 N=A of
urothelial tumours, whilst <=A to <3A have fre;uenc. and d.suria.
+peed of referral and investigation is essential, since the outcome of
treatment for invasive bladder tumours depends on the interval
between the first s.mptom and first treatment. *ll patients are seen
urgentl. at special haematuria clinics.
Urine tests
ipstick testing of the urine is a ver. sensitive method of detecting
haemoglobin in the urine, but the presence of red cells should be
confirmed on microscop.. Urinar. c.tolog. correlates with the
presence of a urothelial tumour in appro?imatel. B=A, but there
are man. false negatives and a negative result should not preclude
further investigation. !rankl. abnormal c.tolog. sometimes
precedes the detection of a transitional cell carcinoma b. all other
means. +uch patients usuall. develop a demonstrable tumour within
a .ear and need careful follow up with repeated investigations.
Intra"enous Uro$ram
etails the upper tract collecting s.stem and ureter in the search for
urothelial tumours and accurate location of calculi. * &U7 560a.,
ultrasound and fle?ible c.stoscop. are the preferred initial
investigations which ma. point to areas on which the radiologist can
concentrate in subse;uent imaging.
Ultrasound of the Urinary Tract % 5U# 6 !ay
This is good for the detection of renal parench.ma tumours and
larger bladder tumours, but is not suitable for the detection of
urothelial tumours of the renal pelvis and ureter. Unless the. are
causing h.dronephrosis or h.droureter a &U7 will demonstrate most
stones.
+le2i,le Cystosco'y
This is performed under local anaesthetic and is used as the initial
diagnostic c.stoscop. in order to speed the diagnosis e.g. at the
Gaematuria Clinic. Patients found to have a bladder tumour can
then be given priorit. admission for resection of their tumour.
8n the case of persistent microscopic haematuria, where the 89U
and c.stoscop. are negative, further investigation for possible
glomerular disease is indicated. *ttention should be paid to blood
pressure, overall renal function, persistent proteinuria and urine
microscop. for casts and d.smorphic red cells. Proteinuria in
association with microscopic haematuria will direct attention to
possible glomerular cause earl. in the investigation.
HAE*OSPE!*IA
7lood in the seminal fluid, with either red or rust. coloured semen
is uncommon, but an alarming s.mptom for the patient. 8t ma.
occur as a single episode, recur over a period of time or be a
persistent feature. 8t can originate from various sites in the genital
tract and, in most cases, the cause is inflammator. and benign 6
almost invariabl. so in the under :=Hs, whilst in the over :=Hs the
occasional malignanc. "prostatic carcinoma, tumour at the bladder
neck or ver. rare seminal vesical carcinoma' can present in this
wa.. The approach therefore recommended is:
+. Under 78s
Gistor., full e?amination including prostate and e?ternal
genitalia. 8nvestigate with an 4+U before and after
prostatic massage and with seminal fluid culture.
*ntibiotic treatment if infection or p.ospermia found,
using antibiotics which penetrate the prostate gland,
such as Trimethoprim, )r.throm.cin Cephalosporins, or
Ciproflo?acin.
$. O"er 78s
8n men over :=, and all ages with persistent
haemospermia or associated haematuria, further
investigation is indicated, including P+* and transrectal
ultrasound to image the prostate and seminal vesicles
"with guided biops. if necessar.'. 0eferral to the
Urolog. Clinic is merited for this latter group of patients.
#ENIGN ENLA!GE*ENT AND CA!CINO*A O+ P!OSTATE
9) #eni$n Prostatic Enlar$ement :#PE;
7oth s.mptoms and benign enlargement of the prostate "7P) Q
$=g' are common ":%A of men between B= and #= .ears of age 6
Garrawa. <NN<' the s.mptoms are not necessaril. related to the
si2e of the prostate. The s.mptoms are not disease specific so
P*T8),T+ 0)JU80) -7R)CT89) *++)++4),T T- *0089) *T *
8*G,-+8+ *, !-04U(*T) *98C).
8t is helpful to screen patients and identif. those who re;uire urgent
referral. * general assessment, including intercurrent disease,
mobilit. etc, is important, together with a dip6stick urine "with a
follow6up 4+U to the lab if necessar.', abdominal e?amination,
digital rectal e?amination "0)' and a serum creatinine to e?clude a
UT8, chronic retention, obvious carcinoma and renal impairment
respectivel.. @) - ,-T 0)C-44), TG) 0-UT8,)
4)*+U0)4),T -! +)0U4 P+*. Gowever, patients often know
about the test "though not its limitations', so the doctor should
have a strateg. for advising patients on the pros and cons of P+*
testing "see below'.
8f no urgent reason to refer is found, the patientHs s.mptoms should
be assessed in terms of their severit. and bother. The ke.
investigation in assessing s.mptoms is the +re/uency olume
Chart "see page N', which shows up inappropriate drinking
patterns, ma?imal functional capacit. of the bladder during the da.
and night and nocturnal pol.uria "over %=A $:6hour urine output
during the night hours'.
+ome hospitals offer a Dfull packageD of initial investigations for
males with urinar. voiding problems at special flow clinics, and
some practices are investing in flowmetr. and bladder ultrasound as
a primar. care facilit..
The diagnosis of Benign Prostatic Obstruction (BPO)
In the urolog. clinic urine flow studies are used to screen patients.
8f the ma?imum flow is S<= mlIs there is a N=A chance of prostatic
obstruction. !or flows Q<=mlIs, specificit. is poor and more than
one third of patients are unobstructed.
* rough guide to the likelihood of ,ladder outlet o,struction can
be obtained b. asking the patient to time voiding using a watch with
a second6hand "average flow e;uals voided volume divided b. time
taken'. The average flow should be assessed from <= voids.
*verage !low
assessed b. patient
QC mlIsec
3 6 C
mlIsec
S3 mlIsec
4a?imum flow using
flowmeter 6 $== ml in
bladder to be valid
Q<3
mlIsec
<= 6 <3
mlIsec
S<= mlIsec
Percentage with
prostatic obstruction
%=A B3A N=A
Pressure flow studies will be carried out if the flow rate is Q <= mlIs
and interventional surger. is being contemplated.
The Management of BPO
+urgical prostate ablation b. TU0P or occasionall. open
prostatectom. is still the gold standard and produces the greatest
measurable and long6term reduction in both s.mptoms and bladder
outlet obstruction. -ther methods of ablation "laser etc' are under
trial. Pharmacotherap. ma. also improve s.mptoms b.
pharmacological action or placebo effect but, with a lesser
measurable reduction both in s.mptoms and in obstruction.
Suggested Plan of Management
Conser"ati"e treatment for mild or moderate sym'toms)
* period of conservative treatment for three months is advised. This
consists of bladder training, advice on fluid intake, pelvic floor
e?ercises, plus or minus an anti6cholinergic drug, if the patient is
thought to have detrusor instabilit. "urge, urge incontinence'. *fter
discussion and reassurance, man. men will ad1ust to mild or
moderate s.mptoms in the absence of severe obstruction and some
will e?perience spontaneous reduction in s.mptoms.
8f conservative treatment fails and the patient wishes to have
further treatment, both drug and surgical therapies should be
discussed.
Dru$ *ana$ement
8f the patient wishes to tr. drug therap., an alpha6blocker is the
first choice since its effect, if an., is immediate, but take care with
the elderl. and those on anti6h.pertensives "h.potension and
di22iness'. !low rates and post6void residuals should be re6
measured at one month.
36*lpha 0eductase 8nhibitors shrink onl. the epithelial part "$3A'
of the gland and take at least B months to achieve ma?imum affect.
P+* 4U+T 7) CG)C&) P08-0 T- T0)*T4),T. ",ote that the. can
also reduce serum P+* b. half in benign and malignant prostate
enlargement so if .ou have reason to check P+* in 36alpha
reductase treated patients, multipl. the result b. $'.
Check flow rates and post void residuals at B months and do not
continue the therap. in the absence of significant sub1ective and
ob1ective benefit. These drugs are still on long6term trial and have,
so far, been found to benefit a minorit. of men.
8f drug therap. fails, or is not chosen, and the patient is sufficientl.
bothered, he should be referred for evaluation with a view to
surger..
Sur$ical Treatment for Persistent *oderate or Se"ere
Sym'toms
8f s.mptoms persist and are troublesome, refer for evaluation for
possible TU0P or alternative prostate ablation. +.mptomatic
patients will have !0 assessed and pressure6flow studies performed
if necessar..
*cute retention: 8f not referred to hospital initiall.,
catheterisation at home and the arrangement for an
urgent outpatient appointment is recommended. 8f the
residual urine on catheterisation is Q <3==ml, we would
recommend immediate admission to hospital, since
some of these patients will have impaired renal function
and the subse;uent diuresis ma. cause further
complications of electrol.te balance.
Chronic retention : 8f urea and electrol.tes are within
normal limits there is no need to catheterise
immediatel., but earl. referral is recommended.
S(*PTO*S SUGGESTIE O+ P!OSTATIC O#ST!UCTION
<) Dia$nosis of Carcinoma of Prostate
Serum PSA . :normal u' 7 n$1ml in the under =8s and u' to
=n$1ml in the elderly;
TG8+ 8+ ,-T * +P)C8!8C T)+T !-0 P0-+T*T) C*,C)0 but can be
a pointer to the diagnosis and a rough staging guide after tissue
diagnosis. 8t is a ver. useful monitor of treatment effectiveness,
e?cept for a minorit. of poorl. differentiated tumours which ma.
e?press P+* onl. at low levels. * P+* within the normal range for
the ma1orit. of men does not e?clude CaP.
@) 0)C-44), CG)C&8,G +)0U4 P+* 8, +/4PT-4*T8C 4),
-,(/ -, C(8,8C*( +U+P8C8-, -! P0-+T*T) C*,C)0, ie rapid
progression of lower urinar. tract s.mptoms "(UT+' in the absence
of infection, suspect 0) T hard prostateInodulesIirregular shape,
associated skeletal pain, famil. histor..
@) - ,-T *98+) 0-UT8,) P-PU(*T8-, +C0)),8,G as there
are still uncertainties about management. * patient with or without
(UT+ re;uesting P+* should be full. informed about the
interpretation and implications of the results before measurement.
4an. patients with lower abnormal results "between : and $=
ngIml' will simpl. have benign disease 6 high results can occur in
prostatitis. The diagnosis of CaP and its grade are made b.
transrectal ultrasound guided biopsies.
The Treatment of CaP
Localised Disease
(ocalised prostatic carcinoma diagnosed in men over #= need not be
a threat. C=A of such patients ultimatel. die of other causes
"Rohanson', but .ounger men and fit men in their #=s, with a life
e?pectanc. of Q <= .ears, risk life6threatening progression and ma.
be suitable for, and wish to have, radical surger.. The treatment
ma. therefore be selective, depending on age, intercurrent
conditions and histological grading. Generall., in patients with a life
e?pectanc. of Q<= .ears, our current recommendations for localised
disease confirmed b. careful staging procedures are :
@ell differentiated tumour: monitor P+* and 0) at B
month intervals.
*verage differentiation : discuss and offer radical
prostatectom., if appropriate.
Poor differentiation: micro6metastases ma. have
alread. occurred and results of surger. ma. not be
good. 0adical radiotherap. is an alternative treatment.
Gowever, in such patients, all three options, watchful
waiting, radical surger. or radiotherap. should be
discussed.
Locally Ad"anced or Disseminated Disease
8n as.mptomatic disseminated disease, hormonal
treatment ma. be dela.ed without affecting longevit.,
but it is probable that tumour associated morbidit. is
less when hormonal treatment is initiated earl..
Patients with s.mptoms should be treated and e?treme
care should be taken in patients who develop back pain,
since a small minorit. ma. develop cord compression
leading to paraplegia. (ong bones are also at risk from
pathological fracture. * bone scan should be carried out
on those in whom metastases are suspected.
Two6thirds of patients will respond to hormone
manipulation and the methods of manipulation should
be discussed with the patient, ie surgical castration
"bilateral orchidectom.', or medical castration.
(G0G analogues are the best method of medical
castration and a variet. are now available. +ince initial
treatment causes increased testosterone levels
associated with s.mptom flare, the patient should be
started on C.proterone *cetate three da.s before the
first (G0G depot in1ection and continued on this for
three weeks "%==mg dail.'.Gigher doses ma. lead to
serious hepatic reactions. CP* ma. also be used as the
treatment for hot flushes after orchidectom. or (G0G
agonists "<==mg dail.' and in patients who have not
responded to, or are intolerant of, other treatments
"%==mg dail.'. (iver function tests before and after
treatment is initiated or when s.mptoms or signs
suggestive of hepatic impairment develop are
recommended.
4onotherap. with *nti6androgens and combined
treatment "total androgen blockade' are under
investigation at present and are likel. to be initiated
from secondar. care.
(ocal radiotherap. to painful and otherwise
unresponsive metastases is usuall. ver. helpful.
Please refer urgentl. to urolog. an. man with prostate cancer who
develops the following : 6 anuria, oliguria, renal failure "suspected
ureteric obstruction', bilateral lower limb I bladder motor or sensor.
loss "suspected cord compression'.
* rough guide to staging of histologicall. proven prostate cancer
with P+* is as follows :
P+* S $= ngIml 6 istant metastases rare
P+* Q := ngIml 6 (ocal invasion andIor l.mph
node metastases common
P+* Q <== ngIml 6 7one metastases likel.
Poorl. differentiated tumours can be under staged since the. ma.
e?press P+* poorl..
SC!OTAL S>ELLINGS
0eferral advised. 4ost scrotal swellings are benign and the
commonest 6 epidid.mal c.sts and h.droceles do not all need
surger.. /oung men are currentl. much more aware of testicular
cancer and the emphasis in investigation now is :6
9) To e2clude cancer)
<) To define the 'atholo$y)
Gistor. of trauma and previous surger., including vasectom., is
important. Post6vasectom. patients ma. complain of pain and
swelling "usuall. epidid.mal' often .ears after the operation.
Testicular tumours are largel. found in the under 3=s.
+crotal ultrasound is much more accurate than clinical e?amination
in defining tumours and other pathologies. 8t is also of therapeutic
value in reassuring man., so is now commonl. used.
*n. patient with a suspected testicular tumour is seen urgentl..
INDICATIONS +O! SC!OTAL ULT!ASOUND
8ntra6testicular lump
@hen unable to distinguish whether lump is intra6
or e?tra6 testicular
Painful scrotal conditions
8mpalpable testicle within h.drocoele of recent
onset
Post traumatic testicle 6 P rupture I haematoma
4alignanc. suspected in palpabl. normal testicle
Scrotal ultrasound is NOT indicated &hen
(ump is clinicall. e?tra6testicular and testicle is
normal
I*POTENCE
0egular specificall. designated outpatient sessions for the further
investigation and treatment of male erectile d.sfunction are held in
the Urolog. -utpatient Clinic at +outhmead Gospital. The. are
staffed b. a consultant, a senior urological trainee, a research
fellow, a general practitioner "$ sessionsIweek' and an androlog.
nurse specialist. ,o special investigations are re;uired before
referral but a comprehensive list of an. medication is helpful.
Patients with cardiovascular disease, often taking beta blockers
andIor thia2ide diuretics are the commonest organic group, followed
b. diabetics. *fter taking a histor. and ph.sical e?amination the
patientHs response to the intra6corporeal in1ection of a vaso active
agent 6 papaverine, prostaglandin )< or mo?is.l.te ")recnos' 6 is
assessed. 8f an erection is produced then the patient is offered
tuition in self in1ection, or the intraurethral deliver. s.stem, 4U+),
is considered as an option. 8f response is poor then vacuum
constriction devices are discussed. +hould these subse;uentl. be
tried and found unsatisfactor., then penile prostheses are
considered. The .ounger non6responders who have no obvious
underl.ing contributor. causes are further investigated with colour
oppler duple? ultrasound scanning of the penile arteries, followed
b. d.namic pharmaco6cavernosometr.. These investigations
identif. patients who ma. benefit from penile revascularisation or
Uvenous leakH surger.. Patients with Pe.ronieHs isease are also
seen in these clinics.
IN+E!TILIT(
* male infertilit. clinic is held on alternate weeks at +outhmead
Gospital Urolog. -utpatient Clinic. 4ost patients are referred from
g.naecologists or female infertilit. clinics when, during the course of
investigation, the male partner is found to have either a2oospermia
or oligospermia. * photocop. of an. semen anal.ses accompan.ing
a re;uest for a patient to be seen is essential. 8f details of a
hormone profile, i.e. plasma testosterone, (G and !+G, are included
then this is useful information which can streamline investigation
and treatment. There is an *8 and *8G programme, but the
waiting list in considerable.
ASECTO*( !EE!SAL
*lthough vasectom. reversal is available under the ,G+ in
e?ceptional circumstances, the priorit. given to it is necessaril. low.
-perating time is valuable and reversal takes between one to one
and a half hours to perform. *lthough it is almost alwa.s possible
from a technical point of view to reverse a previous vasectom.,
sperm ma. not appear in the e1aculate. The ;ualit. of sperm usuall.
declines with the interval between vasectom. and its reversal and
pregnancies are not often achieved after a time span of more than
<= .ears between vasectom. and reversal. @hatever the odds
given to a couple against success in terms of achieving a pregnanc.
most are not dissuaded from surger.. 4icro aspiration of seminal
fluid from the epidid.mis and testis for assisted conception
techni;ues is currentl. undertaken in the Universit. ivision of
-bstetrics and G.naecolog. 7ristol.
PAEDIAT!IC U!OLOG( SECTION
U!INA!( T!ACT IN+ECTIONS
UNDESCENDED TESTIS
PHI*OSIS
ENU!ESIS
P*)8*T08C U08,*0/ T0*CT 8,!)CT8-,+
Urinar. tract infections occur most commonl. in .oung girls and are
often of no great significance. The. are best referred to one of the
Paediatricians initiall. who will carr. out routine investigations and
will refer on an. patients who have a surgical problem. 8nitial
investigations include a plain 56ra. of the abdomen and an
ultrasound of the kidne.s, ureters and bladder. !urther
investigations are onl. undertaken if the ultrasound is abnormal.
Patients with recurrent infections will re;uire a micturating
c.stourethrogram but, since this is such an unpleasant investigation
in children, use is strictl. limited.
8n .oung girls with recurrent infections, da.time urgenc. and
wetting is not infre;uentl. associated due to bladder instabilit..
These patients will re;uire treatment for instabilit. when the
wetting becomes sociall. unacceptable.
P*)8*T08C U,)+C),) T)+T8+
The presence of an undescended testis should be picked up on the
routine postnatal e?amination. Children should be referred for an
opinion at appro?imatel. si? weeks of age so that e?amination ma.
be undertaken before the cremasteric refle? becomes active. 0e6
e?amination is undertaken at nine months of age and, if the testis
remains undescended, surger. is normall. undertaken between the
ages of one and two .ears.
P*)8*T08C PG84-+8+
The foreskin, at birth, is normall. adherent to the glans and is not
retractile. *s the child grows older, the prepuce would normall.
become more retractile, but the age at which this occurs is ver.
variable. ,ot infre;uentl., children under the age of four will get
recurrent bouts of balanitis which is s.mptomaticall. uncomfortable,
but of no lasting harm. The foreskin is often normal and this is not
an indication for circumcision. Patients rarel. have a true phimosis
under the age of four, and, with gentle manipulation, the foreskin
can normall. be partiall. retracted. 8f there is no evidence of the
foreskin becoming retractile, the child should be referred for an
outpatient opinion. The commonest indication for circumcision is
balanitis ?erotica obliterans affecting the foreskin in the older age
group. 4an. patients have retractile foreskins but underl.ing
preputial adhesions and, if b. the age of eight or nine these
preputial adhesions are still present, the. can be freed b. instilling
)mla local anaesthetic cream under the foreskin for an hour. The
adhesions ma. then be freed.
),U0)+8+
)nuresis is rarel. a surgical problem and should be referred to an
appropriate enuretic clinic. 8f there is a particular concern that the
patientHs enuresis is secondar. to another abnormalit., a referral
should then be undertaken, but such an underl.ing patholog. is
e?tremel. rare.
G/0-C)() I P*T),T P0-C)++U+
+urger. normall. advised at the age of $ .ears.