Common urological problems Suline Ahmed GPST 3 BPH

Common urological problems Suline Ahmed GPST 3

BPH �Common in men over the age of 45. It affects the quality of life in 40% of men over the age 50 and 90% over the age of 90. �Afro-American men are more affected more severely possibly due to higher testosterone, 5 alpha reductase androgen receptor activity. �It is a hormone dependent gland BPH does not occur in castrated men.

Diagnosis � A 55 years old man presents with frequency of micturition, the stream is a stop- start, hesitancy and post void dribbling. He also reported getting up at night 4 times to pass urine. His symptoms have been for almost a year. He denied haematuria. Next step? � Focused examination: abdominal exam to look for palpable bladder � Knee/ankle jerk/planter resposne. � DRE: check size/consistency of the prostate. � Urine dip and MSU � Blood: FBC, UEs, LFTs � ? PSA. Make sure you counselled the patient. � KUB USS

Management � You confirmed that the patient has obstructive symptoms. Anything you can use to quantify the impact of the symptoms on the patient? � A: IPSS (0 -7: mild), (8 -19: moderate), (20 -35: severe) � Patient asking what can be done to help him? � A: life style (fluid intake, alcohol, caffeine, fizzy drinks, reduce weight, avoid constipation) � If the patient has IPSS of 8 or more--- offer alpha blocker (when you expect result? , Review? ) � If there is a risk of progression (severe symptoms, elderly, chronic retention)--- 5 alpha- reductase. You will need to review in 3 -6 months. Then every 6 -12 months. � Check PSA in 6 months after starting 5 alpha-reductase to check new baseline (50% reduction).

Management � Patient is asking what side effects he is expecting from starting alpha blocker? � Dizziness (8. 1%), Fatigue (asthenia) (5. 4%), Postural hypotension (2. 5%), Nasal congestion (6. 1%), Erectile dysfunction (3. 0%), Abnormal ejaculation (2. 2%), Drowsiness. � What about 5 alph-reductase? � Fewer than one in 10 men experience adverse effects (such as sexual dysfunction and breast tenderness) in the first year of use. Report breast lump, tenderness, and nipple discharge. � Sexual dysfunction tends to improve with duration of treatment. � Any advice to the patient regards using 5 alph-reductase if partner still fertile? � A: use condoms. 5 alph reductase execrated in the semen and absorbed through the skin.

Management � A year later, the patient comes back for a review. His IPSS score was 25. He is troubled by his symptoms. He gave up his job as a taxi driver. He is asking for help. What is the next step? � A: refer � Secondary care: 1 - intermittent catheterisation � 2 - TURP/Ho. LEP � 3 - Long term catheter

� You were asked to see a patient as a home visit. His carer noted that the patient has not passed urine for 2 days. You checked his record and found that the patient has BPH and currently taking tamsulosin and finasteride. He has recently started on furosemide by his cardiologist following recent consultation on managing severe heart failure which left him house bound. You examined the abdomen and found the patient has palpable bladder. What will you do? � A: refer � The patient went to AE and had a catheter fitted. They drained 2 litres out of the bladder. His creatinine was 300. After catheterisation, his renal function normalised and the patient was discharge home. 2 weeks later, the patient asked for a home visit to discuss what needs to be done about the catheter. What will be your advice? � A: counsel him, likely LTC.

� A 55 years old man comes to see you following blood result. He has LUTs symptoms for which you prescribed tamsulosin for BPH. You requested PSA on the previous visit as the patient wished which came back high (5 ng/ml). What will you do? � A: repeat the test and address the following: � an active urinary infection (PSA may be raised for many months) � ejaculated in the previous 48 hours � exercised vigorously in the previous 48 hours � or had a prostate biopsy in the previous 6 weeks � had a DRE within the previous week (1) � The same patient but his PSA was 25 ng/ml? � A: refer

�The patient is asking what are the chances of cancer with his level of 5 ng/ml? �A: 33% �What are the chances of cancer with normal PSA? �A: 20% �Is PSA a reliable screening test? �Mixed evidence. However, men over age of 50 can have it free on the NHS (after you counselled the patient!).

� A 60 years old women presented with embarrassing symptom. She said that she leaks urine every time she cough and laughs. No dysuria. No haematuria. PMHX: long term constipation. Obstetric hx: 5 vaginal deliveries. What is the diagnosis? � A: Stress incontinence � How will you treat? � A: general measures (reduce caffeine intake, fluid intake, weight loss, smoking) � Pelvic floor exercise (3 months). � Incontinence pads � Patient tried these measures but all failed. She is active and goes to the gym regularly but find this issue embarrassing. What will you do? � A: refer. (mid-urethral tape, colposuspension, artificial sphincter).

�You explained surgical options but the patient felt surgery is not for her. What is your alternative? �A: duloxetine (40 mg BD). Reduce if SE (mainly nausea, dry mouth, constipation).

� A 30 years old women presented with urgency of micturition. This has been going on for 6 months. It has worsened over time to the point that she even stopped going out. There is no dysuria or haematuria. Her past medical history was unremarkable. Her abdominal exam was normal. What is the likely diagnosis: � A: Over active bladder. � What is your management? � Bladder training (bladder drill), diary (3 days). � Maintaining a healthy lifestyle (with respect to body weight, exercise, diet, smoking, and alcohol consumption). � Limiting intake of caffeine, artificial sweeteners, and fizzy drinks. � Refer to local continence service.

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Patient comes back 8 weeks later. Her symptoms no better and would like to try something else. What can you give? A: antimuscarinic. -Oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation) can be used first line. **Do not offer oxybutynin (immediate release) to frail older men due to the risk of impairment of daily functioning, chronic confusion, or acute delirium (less common). - If an antimuscarinic drug is contraindicated, not tolerated, or not effective, offer mirabegron (depending on local prescribing policy). ** Treatment with botulinum toxin A.