Urology Check

Question 1

If a patient does not respond initially to PDE5 inhibitor whats your approach? What advice needs to be given?

Answer 1

• It is recommended that oral PDE5 inhibitor medications are initially administered at a maximum dose to improve (guarantee) erection and subsequently are decreased to a lower dose based on adverse profile.
• It is important to try at least two different types of PDE5 inhibitor medications.
• The patient should be encouraged to take the PDE5 inhibitor medication on four separate occasions, preferably by himself initially to minimise any psychological distress related to sexual intimacy with another person
• Sexual health and safe sex practice should be discussed, and this forms part of opportunistic and relevant duty of care for the patient.
• Common complications caused by PDE5 inhibitors include headache, facial flushing, indigestion, nasal congestion, dizziness, visual disturbances and myalgia.
• Daily tadalafil therapy may provide greater sexual spontaneity and remove part of the psychological distress that the man feels when he takes medication for sexual dysfunction

Question 2

What advice would you give about Shockwave or regenerative therapy for ED?

Answer 2

Shockwave - lack of standardised treatment protocols and unknown longer-term physiological effect in penile tissues.

Also recommended to occur in a clinical setting.

May be Useful for mild to moderate ED, younger age groups, no CV risk/comorbs

Regen therapy - eg stem cell/platelet rich injections are experimental

Question 3

What is known about prostate cancer survivorship and ED

Answer 3

post–radical prostatectomy ED is as high as 60% and, while ED occurs immediately postoperatively, erectile function can return once neuropraxia subsides in the following 6–18 months.

Conversely, the use of radiation therapy and androgen deprivation therapy invariably worsens erectile function and often result in the development of medically refractory ED.

The presence of ED is often associated with loss in penile size. This is related to underlying cavernosal hypoxia and subsequent cavernosal fibrosis. It is important to acknowledge the effect the myriad of male sexual dysfunctions such as low libido, anejaculation and orgasmic issues, as well as the presence of other confounding factors including urinary or bowel complications, alteration in partner dynamics and social network, have on the recovery of sexual function

Question 4

What is penile rehabilitation

Answer 4

Penile rehabilitation using phosphodiesterase type 5 (PDE5) inhibitors is considered the standard of care, especially in patients who received nerve-sparing radical prostatectomy. It is recommended that this treatment commences as soon as possible to protect and prevent corporal hypoxia and fibrosis.

While there is no consensus on the exact timing, dose and duration of PDE5 inhibitors, and their impact in non–nerve sparing surgery and other forms of prostate cancer treatment modalities, it is recommended that regular use of PDE5 inhibitors and appropriate escalation of pro-erectile treatment strategies be discussed in the context of prostate cancer survivorship.

The use of intracavernosal injection therapy and/or a vacuum erection device can be offered to men who wish to remain sexually active and preserve their penile length

Question 5

Is there a role for prosthesis surgery in penile rehab

Answer 5

Penile prosthesis surgery should not always be the last resort in the treatment algorithm for penile rehabilitation, provided there is adequate counselling and that the patient understands that this is an irreversible surgical option.

Excellent clinical outcomes and patient satisfaction rates.

Question 6

Patients presenting with polyuria? DDx

Answer 6

DM

DI

Excessive fluid intake

Medications eg diuretics

Keep 24 hour bladder diary

Question 7

DDx for storage issues causing incontinence

Answer 7

1. Increased afferent sensitivity due to inflammation.
2. Decreased bladder compliance.
3. Decreased bladder capacity (Eg post pelvic Radiotx)

Question 8

Ddx for irritative urinary symptoms

Answer 8

1. UTI
2. Detrusor overactivity secondary to a neurological cause eg MS.
3. Intravesical pathology eg bladder cancer
4. screen for urothelial cancer (smoking)

Question 9

DDx of poor bladder emptying

Answer 9

Chronic urinary retention secondary to:

Autonomic neuropathy eg DM

Structural issue eg uterine prolapse

Question 10

DDx when older female p/w frequency

Answer 10

1. Polyuria - Endo/Intake/Diuresis
2. Irritative symptoms - Infection/Detrusor? -neuro/cancer
3. Storage issues - afferent sensitivity(inflamm)/reduced capacity/reduced compliance
4. Poor emptying - chronic urinary retention - structural(prolapse)/autonomic neuropathy eg DM

Question 11

Managment of woman with frequency/urgency and white cells on urine dipstick

Answer 11

1. Trimethoprim 300mg daily for three days.
2. You request an MSU culture to be done prior to commencing the three-day antibiotic course.
3. You also ask Manjusha to keep a 24-hour bladder diary if her symptoms do not completely resolve,
4. and provide lifestyle advice regarding intake of fluids and caffeine.
5. A telephone review is scheduled for two weeks’ time.

Question 12

How do you collect an MSU and minimse chance of contamination with vaginal flora

Answer 12

To collect an adequate specimen:

1. the patient should first wash their hands,
2. separate the labia and wash the urethral meatus once with a sterilising wipe.
3. While maintaining separation of the labia, the patient should void the first part of the urine into the toilet and then, without interrupting the urine flow, pass the sterile collection container under the stream until it is approximately half full.
4. The patient then completes the void into the toilet.
5. The specimen should be returned to the lab for processing as soon as possible or refrigerated if there is a significant delay.

Failure to collect the sample properly may lead to contamination of the specimen with vaginal flora.

Question 13

What diagnosis can be missed with KUB ultrasound for patient with irritative urinary symptoms?

Answer 13

Persistent microscopic haematuria in the context of irritative lower urinary tract symptoms and a smoking history raises a red flag for urothelial carcinoma of the bladder.

Normal bladder ultrasonography does not rule out the presence of malignant disease, as papillary lesions may be small and overlooked, and carcinoma in situ (which classically presents with irritative voiding symptoms) is flat and will not be detected.

Question 14

What are risk factors for bladder malignancy

Answer 14

The most important modifiable risk factor is smoking,

but others include

• prior cytotoxic chemotherapy or pelvic radiation,
• occupational chemical exposure
• and chronic bladder irritation.

Question 15

What are the risk factors for Prostate cancer?

Answer 15

1. with increasing age – one in six men will develop prostate cancer by the age of 85 years
2. with a family history of prostate cancer (two times the risk if one first-degree relative has a prostate cancer diagnosis, and 9–10 times the risk if more than two first-degree relatives have a prostate cancer diagnosis)
3. of African American ethnicity
4. who carry the BRCA gene mutation – BRCA1/2 mutations confer a more aggressive prostate cancer phenotype with a higher probability of nodal involvement and distant metastasis, and BRCA mutations are associated with poor survival outcomes.2 BRCA2 mutation carriage is an independent prognostic factor associated with poorer outcomes3
5. who have a family history of cancers associated with hereditary breast–ovarian cancer syndrome or Lynch syndrome (eg colorectal, endometrial, melanoma, pancreatic, urothelial cancer).

Question 16

When should a DRE be performed in prostatic screening/mx

Answer 16

IF SYMPTOMATIC - then appropriate

if asymptomatic then not appropriate in GP

May also be appropriate in surveillance post diagnosis with prostatic ca

Question 17

What risks should a patient be informed of when they present for PSA?

Answer 17

Testing may not identify a man with a higher-grade, clinically significant prostate cancer if the PSA is not elevated (false negative). A low PSA result (below the threshold to perform further testing) may fail to detect cancer at an early stage.

Additional testing to identify the cause of elevated PSA is associated with morbidity of biopsy side effects as well as anxiety. Risks of prostate biopsy include:

transrectal ultrasound-guided biopsy – bleeding, sepsis, hospitalisation, rarely death

transperineal biopsy – perineal haematoma, obstructed micturition, temporary erectile dysfunction, perineal pain

Testing may result in radical treatment for prostate cancer with surgery or radiotherapy for a clinically insignificant cancer that would not have caused any harm had it not been diagnosed (overtreatment and overdiagnosis). These treatments have significant side effects affecting urinary continence, sexual function and bowel function as well as mental health effects. Known possible effects of radical prostate cancer treatments include:

prostatectomy – urinary incontinence and erectile dysfunction, and surgical anaesthetic risks

external beam radiotherapy – cystitis, proctitis and, later, erectile dysfunction

sterility following treatment.

Question 18

What advice should be given prior to PSA testing

Answer 18

ejaculated or exercise vigorously during the previous 48 hours

an active urinary infection (PSA may remain raised for several months)

had a prostate biopsy in the previous six weeks, as this investigation can cause PSA levels to rise temporarily, which may affect the test results.

Question 19

History questions in LUTS in male

Answer 19

LUTS

Voding symptoms: hesitancy, straining, poor stream and terminal dribbling,

and storage symptoms such as urinary frequency, urgency, incontinence and nocturia.

A history of fluid intake and output is also important

. A bladder diary can help further ascertain the pattern and timing of symptoms, while validated symptom scores can help quantify them and assist serial assessment

Past Medical History: A medical history should be sought regarding urinary tract infections (UTIs) and sexually transmissible infections (STIs), as well as urethral instrumentation. It is also important to enquire about medication use, diabetes and the presence of back injuries or neurological conditions.

Risk factors for Bladder cancer: Cigarette smoking and occupational chemical exposure need to be elicited as potential risks for bladder cancer.

The patient should also be asked about any family history of benign prostatic hyperplasia (BPH) or prostate cancer.

Question 21

What are the complications of BPH

Answer 21

Complications of BPH include

 UTIs,

urinary retention (which may be painful or painless),

obstructive uropathy (usually without any flank pain) and incontinence.

Question 22

Managment of BPH

Answer 22

1. Lifestyle mods - nocturnal drinking advice
2. Alpha blockers - eg tamsulosin oral daily
3. Add 5 alpha reductase inhibitor eg finasteride (Can cause gynaecomastia, loss of libidio and ED)
4. If detrusor instability may benefit from anticholinergic eg oxybutinin
5. Continence nurse - bladder retraining exercises
6. Pelvic physiotherapy

Question 23

When would you refer BPH

Answer 23

if someone has complications: UTI/obstructive uropathy/retention

OR haematuria

They could do : urodynamics/cystoscopy/CT IVP etc/ post void residuals

Question 24

Surgical Rx of BPH

Answer 24

TURP

or Open enucleation of prostate

• most common complication is loss of ejaculation (ED and incontinence risk is low), can get recurrent urinary obstruction or regrowth

less invasive - urethral lift, steam and jet ablation

Question 25

Answer 25

stages of kidney disease

Question 26

Patients in stage 3-5 kidney disease are at increased risk of AKI during illness or unable to maintain adequate fluid intake (Eg gastro) which drugs should be temporarily withheld during htis time?

Answer 26

SAD MANS (**S**ulfonylureas, **A**ngiotensin converting enzyme [ACE] inhibitors, **D**iuretics, **M**etformin, **A**ngiotensin receptor blockers [ARBs], **N**on-steroidal anti-inflammatories, **S**odium–glucose co-transporter-2 [SGLT2] inhibitors).

Question 27

What is ESKD? What management?

Answer 27

End-stage kidney disease (ESKD), defined as an eGFR of **\<15 mL/minute/1.73m2**, can be managed by three pathways: **dialysis, kidney transplantation or conservatively, without dialysis**. In the modern era, there is a growing recognition that dialysis does not benefit every patient with ESKD. Patients with advanced age, significant comorbidities and poor functional status may not gain a survival benefit with dialysis when compared with being managed conservatively.