CHAPTER 3:
UROLOGY FOR OSCES
1. Urology histories Page 2
2. Common conditions: Investigations
& management Page 5
3. Performing a urine dipstick Page 7
4. Taking a MSU sample Page 7
5. Urinary catheterisation Page 8
Urology histories:
1. BPH:
- PC: Frequency
Noctura
Haematuria
Dysuria
Retention
Urgency
Similar problems in past
- PMH: Major illnesses/ops
DM (polyuria/polydipsia/UTIs)
STDs
Menstrual cycle
- FH: Prostate cancer/ BPH
- Social: Smoking, alcohol, drugs
Family, home, stairs
Occupation
- Systems review:
General- weight loss, night sweats, fever, fatigue, appetite
CVS- chest pain, SoB, ankle swelling, palpitations, PND, orthopnoea, syncope
GI- abdo pain, bowel motions, n&v, rectal bleeding, haematemesis, weight
change, swallowing
GU- waterworks’ frequency, haematuria, dysura, menstrual cycle
Neuro- headache, dizziness, hearing, vision, pins and needles
Musc- joint pain/swelling/stiffness
2. Urinary retention:
Obstruction or reduced detrussor power (layer of urinary bladder wall)
Bladder outflow obstruction is usually due to BPH or prostate cancer but other causes
are:
1. Bladder neck obstruction (young, middleaged men, bladder neck dysfunction, tx
is bladder neck incision/ drugs)
2. Urethral stricture (due to urethral trauma, catheterisation, previous
ccccccctransurethral STDs such as gonorrhoea. Tx: urethrotomy, dilators.)
3. Bladder calculi
As well as urinary retention obstruction can cause other complications e.g. UTI (due to
urinary stasis), bladder calculi and hydronephrosis.
Retention is a medical emergency
Acute= painful, chronic= painless
- Duration of symptoms
- Previous flow- progressive worsening?
- Frequency
- Nocturia
- Hesitancy
- Terminal dribbling
- Urgency
- Incomplete voiding
- Incontinence
- Poor stream
- Dysuria
- Haematuria
- Suprapubic pain
- Constipation
- Effect on life
Irritative symptoms e.g. UTI, Obstructive symptoms e.g. BPH,
obstruction, uraema, DM, polydipsia, strictures, tumours, urethral valve or
detrussor instability bladder neck contracture
Freqency Hesitancy
Nocturia Incontinence
Urgency Poor stream
Incomplete voiding Terminal dribbling
Dysuria
Chronic retention:
Presentation: overflow incontinence, lower abdominal mass, UTI, renal failure
Causes:
Prostate enlargement (most commonly)
Pelvic malignancy
Rectal surgery
DM
CNS disease
Management:
Examine: PR, Abdomen, perineal sensation (cauda equine compression)
Invx: MSU, U&E, FBC, PSA and urine flow. Renal US if impairment
Prevention: Finasteride, TURP
3. Acute renal failure:
- Duration
- Systemic features:
Uraemia (nausea, vomiting, anorexia)
Decreased urine output
Rash, myalgia, arthralgia, headache
- PMH:
Vascular disease
Childhood renal disease
UTIs
Diabetes
HTN
- FH:
Strokes
Sudden death
- LOOK FOR:
- Features indicating underlying cause e.g. dehydrated, hypotensive
- Features of systemic disease e.g. SLE, vasculitis
- Bladder? Palpable kidneys?
- For complications?
- Volume status of the patient (low volume causes ARF, but ARF causes volume
overload)
- Urine microscopy for cells and casts
4. Haematuria:
- Duration
- Nature of blood i.e. frank. 20% with frank haematuria have a urological malignancy.
- Ensure its definitely in the urine, not vagina/rectum
- Ensure its ‘true’ haematuria, i.e. not due to rifampicin, nitrofurantoin, foods e.g.
beetroot, systemic disease e.g. porphyrias, rhabdomyolysis
- Associated urinary symptoms:
Frequency
Urgency
Hesitancy
Dysuria
- Beginning/end of stream?
If beginning urethral/prostate problem
If throughout lesion in bladder, ureters or kidney
End of stream only unusual
- Presence of clots?
- Associated systemic symptoms:
Malaise
Anorexia
Weight loss
Lethargy
More sinister if painless
- PMH
- Social hx- smoking, drugs, alcohol
General Causes: Local Causes:
Bleeding disorders Infections (TB,
schistosomiasis, UTI)
Leukaemia Stones
Anticoagulants Trauma
Haemoglobinopathies Tumours
Sickle cell disease Glomerulonephritis
Investigations: (for macroscopic, do IVU + cystoscopy. If normal USS)
1. Urine: dipstick (microscopy, culture, cytology)
2. Blood: FBC (anaemia), U&Es (renal function)
3. Radiology: KUB with IVU. U/S for tumours of renal parenchyma. If you see a mass, do CT
4. Special tests: Cytoscopy, early morning urine samples for TB, angiography (for AV
malformations)
5. Pyelonephritis secondary to recurrent UTIs:
- Duration
- Associated urinary symptoms:
Frequency
Dysuria
Colour change (cloudy)
- Systemic symptoms:
Pain
Fever
Nausea and vomiting
- Sexual history
- Previous episodes
Common conditions: Investigation &
Management
1. Prostate cancer: 2. BPH:
Invx: U&Es, PSA Invx: U&Es
Transrectal U/S Renal U/S ( shows upper
Prostate biopsy tract dilation)
(adenocarcinoma) PSA (>10 makes cancer
CT for staging more likely.)
Tx: Conservative Urine flow test (for
Radiotherapy + residual volume)
prostatectomy Voiding diary?
Goserelin (LHRH agonist) Tx: Tamsulosin (alpha
Cyproterone acetate antagonist)
(antiandrogen) Finasteride (5 alpha
Orchidectomy reductase inhibitor)
TURP Catheter
TURP
3. Renal Stones: 4. UTI:
Invx: KUB/IVU Invx: MSU
CT Dipstick- nitrites
MSU, U&Es, Ca2+ IVU + U/S
Tx: Analgesia Tx: Antibiotics e.g.
<5mm- passes itself amoxicillin
Extracorporeal shock Increase fluid intake
wave lithotripsy (ESWL) Prevention: Voiding before
Uretroscopy bed and after sex
Percutaneous Avoid spermicidal jellies
nephrolithotomy
Open surgery
Prevention 5. Acute Renal
Drink lots Failure:
If high Ca2+, reduce
intake or use thiazide Invx: Blood count (anaemia,
diuretics ESR)
If infection, antibiotics Blood culture
If uric acid, allopurinol Microscopy
If cysteine, penicillamine U&Es- Ca2+, phosphate,
uric acid
U/S
6. Chronic Renal Renal biopsy
Failure: Tx: Fluid balance
Nutrition
Invx: (as acute) Nursing
Tx: EPO Adjust drug doses
Vit D analogue Dialysis?
Ion exchange resins
NaCO3
Transplant/ dialysis
7. Renal cell cancer:
8. Testicular tumours: Invx: 50% found incidentally
on US/CT
Invx: U/S (excludes cystic 1% present with
mass) varicocoele (obstruction
Serum AFP,bHCG of renal vein)
CT chest, adbo, pelvis US for diagnosis
Tx: Orchidectomy CT for staging
Seminomas Tx: Radical or partial
radiosensitive but not nephrectomy
teratomas
Performing a Urine Dipstick:
1. Wash hands
2. Check expiry date of BM test 5L pot
3. Put on GLOVES & APRON
4. Check COLOUR & PARTICULATES of urine
5. Immerse dipstick briefly into urine
6. Hold dipstick against colour chart after time stated on container
7. Report reading
8. Dispose of dipstick
9. Wash hands
Taking a Mid-Stream Urine sample (MSU)
1. “Good afternoon my name is Reenam Khan and I’m a third year medical student. Can
I confirm your name and date of birth please?”
2. “I understand that we need a mid-stream urine sample from you, is this correct?”
3. “I’m just going to explain how this is done, would that be ok?”
4. “Have you ever performed an MSU before?”
5. “You will need:
i. Container of sterile water
ii. Gauze
iii. Sterile container”
6. “You will need to wash your penis/ vulva very carefully” (we’re supposed to give
clear instructions)...
7. “Then start passing urine”
8. “Stop urinating & collect urine into the container, or catch the middle of the stream
& empty the rest of the bladder as usual”
9. “Have you any questions?”
10. “Thank you”
Questions:
What tests are done in the lab on an MSU sample?
o Microscopy & cultures & sensitivities
If the test was positive for blood, what might this indicate?
1. Trauma 5. Stone
2. Infection 6. Torsion
3. Nephritis 7. TB
4. Carcinoma
Urinary Catheterisation
Beginning
1. Good morning, my name is ..............., and I’m a third year medical student
2. The doctor has asked me to insert a think tube into your front passage to allow you
to pass water more easily. Would that be OK?
3. Can I confirm your name and your date of birth please?
4. Do you know why you’re going to have the catheter put in?/ Can I confirm that
you’re having this procedure because....’
5. Have you ever had a catheter put in before?
6. Well, a catheter is a long, thin, flexible tube that will be inserted through your front
passage, and when this is inserted, it will be easier for you to pass water any water
you pass will go into a bag that will be attached to your leg’
7. Do you have any allergies?
8. I am going to numb the area that the tube will be inserted into using a local
anaesthetic.
9. The procedure shouldn’t hurt, but it may feel uncomfortable.
10. If you’re in pain at any point, then please let me know, and I will stop.
11. Are you in any pain or discomfort now?
12. Are there any questions you would like to ask me?
13. There will be a chaperone present throughout the procedure to ensure your safety.
Is that OK?
14. You will need to remove your trousers and your underwear for this procedure, so
could you undress behind the screen whilst I go to wash my hands?
15. You will need to lie down on your back with your legs slightly apart.
16. WASH HANDS
Procedure
1. Prepare equipment:
a. Catheter size 14/16
b. Catheter bag
c. Catheterisation pack
d. Sterile saline (10ml) in a syringe
e. Lignocaine gel (10 ml) in syringe
f. Water to inflate catheter balloon
g. Sterile gloves
2. Sterile field on trolley
3. Drop catheter onto field (Foley catheter if indwelling; Nelaton if only for drainage)
4. Drop gloves onto field
5. Put catheter bag on bottom of trolley
6. Pour saline into dish
7. WASH HANDS
8. Put on gloves
9. Cut hole into sterile drape
10. “I’m now going to clean around the area that I will insert the catheter. You will feel a
cold sensation”
11. Retract foreskin
12. Grasp penis firmly with a swab held in the non-dominant hand.
13. Clean penis with single pass of saline-soaked swab, moving from meatus towards
perineum.
14. Clean around glans using all the cotton wool buds
15. “I’m now going to put some anaesthetic gel in. It may sting”
16. Hold the penis right up
17. Squeeze gel into urethra, and close end of urethra to stop the gel oozing out
18. “IDEALLY, I WOULD ALLOW 5 MINS FOR THE LOCAL ANAESTHETIC TO TAKE EFFECT
BEFORE I INSERT THE CATHETER”
19. Place kidney dish underneath penis
20. Open the catheter’s inner covering
21. WARN THE PATIENT- “I’m going to insert the catheter now, and tell me if there is any
pain at any point, and I will stop”
22. Insert it gently into the meatus & feed it steadily in
23. If it gets stuck, try pulling the penis down gently, which straightens the urethra.
24. When AND ONLY WHEN urine flows out, it is safe to inflate the balloon with the
specified amount of fluid- pull in it gently to ensure that the balloon is inflated
25. Attach the catheter to the leg bag, ensuring that the bag’s emptying port is in the
‘off’ position.
End
1. Remove the drape
2. Ensure that the foreskin is pulled down over the glans. Failure to do this will
result in a painful PARAPHIMOSIS.
3. Clear up
4. WASH HANDS
5. Ensure patient is comfortable
6. Document in notes
7. Note down residual volume
8. “Are you OK?
9. You can get dressed now”
Notes
On reaching the membranous part of the urethra, a slight resistance is felt due to the
urethral sphincter & the surrounding rigid perineal membrane- at this point, if you lower the
penis towards the thighs, the catheter will pass more easily
Extra Questions
1. What are the indications for catheterisation?
i. Urinary retention
ii. Urinary incontinence
iii. When the patient is temporarily incapacitated: surgery, severe illness,
trauma, ITU
iv. To monitor urine output, e.g. in the case of acute renal failure
v. To give intra-vesical chemotherapy
vi. Investigation, e.g. micturating cystouretography
2. What are the contraindications for catheterisation?
i. Suspected urethral injury, e.g. perineal bruising, blood at the meatus
ii. History of urethral strictures, or false passages
3. What are the possible complications of catheterisation?
i. Pain
ii. Infection
iii. Irritation & possible stricture if a rubber (not silicone) catheter is left in place
more than 3 weeks.
4. Why might no urine come out of the catheter?
i. Catheter tip blocked with jelly? Flush with saline
ii. Tip may be misplaced
iii. May be no urine in the bladder (e.g. patient is in acute renal failure &
suprapubic tenderness misattributed to bladder distension)