A 40 year old postman has come to the GP complaining of gradually increasing dysuria and frequency of micturation. All physical examinations are normal.
UDT shows large number of leukocytes and bacili and positive for proteins and nitrites.
Discuss the condition with the patient.
Condition: Urinary tract infection
(Most likely- lower urinary tract because no fever or loin pain)
Cause: According to age groups (males)
1. Children: Congenital anomaly especially Vesicoureteric Reflux
2. Young males:
- bacteria from the gut or anal canal invading the bladder
- STI
3. Older males:
- Stones (in kidney, ureter or bladder)
- Prostrate: Prostatitis, BPH, Prostrate Carcinoma
- Bladder Polyps and Carcinoma
- Urethral stricture
- Genitourinary TBCommonality: Very common in women but not very common in men. That’s why investigating further is mandatory.
Clinical features:
1. Pain/burning during peeing
2. Need to go to the toilet more often
3. Fever
4. Tummy pain
5. Nausea/vomiting
6. Discharge from the urethra
7. Blood in urine
Course: Must be treated immediately
Complications: According to the cause
A 40 year old postman has come to the GP complaining of gradually increasing dysuria and frequency of micturation. All physical examinations are normal.
UDT shows large number of leukocytes and bacili and positive for proteins and nitrites.
Tell the management plan.
- Send urine sample for culture and sensitivity
- Start antibiotic therapy immediately:
- Trimethoprim once daily for 14 days
- Cephalexin 12 hourly
- Amoxicillin - Drink extra fluids
- Further investigation is NECESSARY for identifying the cause and excluding malignancy
- Urine MCS (before and after the antibiotic course)
- USG of the KUB : for any structural abnormality
- CT of the abdomen and pelvis : for stones
- PSA : Prostatitis, BPH, Prostrate Cancer
- Serum UEC
- Cystoscopy
- Voiding cystourethrogram - Refer to urologist for
-Cystoscopy
-Voiding cystourethrogram
25 year old man presents to the ED with severe right sided abdominal pain which started two hours ago, radiated to the right groin and testes. There are no other symptoms and all physical examinations are normal.
UDT shows blood.
What investigations will you do?
- Urine for MCS - to exclude infection
- CT (non contrast) or Abdominal Xray- to identify the site of the stone (even very small stones) and any obstruction in the urinary tract.
- USG of the KUB - to see any structural abnormalities
- Examination of the stone to determine it’s type
- Serum uric acid levels
- Serum calcium levels
- Parathyroid hormones level
25 year old man presents to the ED with severe right sided abdominal pain which started two hours ago, radiated to the right groin and testes. There are no other symptoms and all physical examinations are normal.
UDT shows blood.
Tell the diagnosis and management of this patient.
Diagnosis: Renal Colic due to a stone in the right ureter.
The pain is because the stone is passing from the kidney to the bladder through the ureter.
Management:
1. Exaplain the condition and reassurance
- the stone usually passes down simultaneously
- takes one to two days
- you will know that you have passed the stone when you’ll need to strain your urine
- Investigations and why are they necessary
- Give painkillers: Pethidine or NSAIDs for further pain relief
- Increase fluid intake
- Tell the patient to pass all the urine everytime in a container, and save any stones for analysis
- Refer to urologist if:
- stone does not pass within 48 hours
- pain worsens
- pain recurs - Invasive interventions:
- Open operation
- Endoscopic removal
- Destruction by ultrasound
(depending on the size and site of the stone)
Indications for intervention:
- large stones not likely to pass spontaneously
- infection caused by the stone
- persistence of pain
- Follow up in a couple of days with investigation reports
Causes of dark urine (hematuria)
- Kidney :
1. UTI
2. Trauma
3. Stones - Renal Colic
4. IgA Nephropathy
5. PSGN
6. Polycystic Kidney Discase - Ureter :
1. Trauma
2. Stone in the ureter
3. UTI - Bladder :
1. Trauma
2. Tumour / Ca Bladder
3. Infection (UTI)- Stone
- Urethra : -
1. Urethritis- STI or UTI
2. Trauma
3. Stone - Prostrate :
1. BPH
2. Ca Prostrate
3. Prostatitis - Bleeding Disonder & HSP
- Anticoagulants
- Diet - Bee/root, Red vegetables.
A middle-aged man comes to the ED with increasing abdominal pain for the last 12 hours.
The pain did not decrease with painkillers.
What is the diagnosis and management of this condition?
Condition : Benign Prostratic Hypertrophy
(Enlargement of a peanut shaped gland called prostrate gland, situated beneath your bladder. As it becomes enlarged in size, it can obstruct the urethra and cause retention of urine)
Common
Cause : Age
Clinical features : Lower urinary tract symptoms
Management:
1. First relieve the acute retention of urine by inserting sterile Foleys catheter
- Investigations:
- Urine for microscopy, culture, andsensitivity
Blood investigations :
- Serum urea, electrolyte and creatinine
- Serum PSA level (most important)
Imaging :
USG of the KUB region - Refer
- Refer to the specialist
- for voiding flow and bladder scan to check for obstruction
- He will review the investigations, -may decide to do a transrectal biopsy of the prostrate, if anything comes positive in the PSA and ultrasound - They might start you on some drugs called tramsulosine.
The chances for surgery will happen in very advanced cases.
Causes of acute retention of urine in male
- BPH
- Stones
- UTI
- STI
- Trauma
- Tumour
- Herpes
- Psychogenic
Diseases checked in the STI screening
Diseases in the STI screening :
- Chlamydia
- Syphilis
- Gonorrhoea
- HIV
- Hepatitis B and C
Investigations done in STI screening
Investigations in STI screening :
1. First pass you sample
- PCR for chlamydia
- Cervical swab
Penile swab
Throat swab
Anorectal swab
- For chlamydia and gonorrhoea - Blood serology for hepatitis B and C, and HIV
- VDRL for syphilis
- Basic blood test
22 years old male with history of unprotected sex in Bali comes for his test results from last visit. The test is positive for chlamydia.
Explain the diagnosis to the patient.
Condition - Chlamydia
Cause - Bacteria/Bug called Chlamydia Trachomatis
- Transmitted through unprotected sexual intercourse - vaginal, anal & oral
Commonality - Most common STI in the world
Clinical Features -
Male
1. 40 % men ane asymptomatic
2. Tummy pain
3. Dischange from penis: white and clear
4. Itching, rash, ulcers
5. Spots on underpants or wetness in the groin area
Complications :
1. pain becomes more severe
2. Discharge becomes thicker and smelly
3. Infections spread to prostrate and testes
22 years old male with history of unprotected sex in Bali comes for his test results from last visit. The test is positive for Chlamydia.
What is the management of this condition?
Management
1. Reassunance
2. Refer for further Investigations
3. Rx :
If symptomatic - Doxycycline
If asymptomatic - Azithromycin for 7 days
4. Notify DHS
- Advice:
- Inform your partner (all in 6months)
- Partner needs to be tested and treated as well
- No sex during infection going on
- Safe sex !
6 Repeat tests in 3 months
- Red Flags + 5R .
A young woman has come to the GP to enquire about sexually transmitted infections and screen herself for sexually transmitted infections.
What history will you take?
- STI symptoms in female:
- fever
- Tummy pain
- Vaginal discharge
- Itching
- Rash, ulcers, or vesicles down below - Well person questions
- 5P questions
Sexual history (in details) - SADMA COT FP
An 18 year year-old boy presented to the ED due to right-sided, groin pain and vomiting since 3 hours after riding a bicycle
What can be the possible causes?
- Testicular Torsion
- Trauma
- Epididymo-orchitis
- Strangulated hennia
- Incarcerated hernia
- UTI / Pyelonephritis
- Renal stone
- Acute Appendicitis
- Intestinal Obstruction
Management of testicular torsion
Condition- Testicular torsion (Draw picture)
• Your testes are suspended by a cord inside the scrotum.
• These cords have blood vessels that supply blood to the testes.
• Sometimes these chords can get twisted around each other.
• This cuts off the blood supply to the testes and you have pain.
Emergency condition
Must be untwisted ASAP to restore the blood supply and prevent further damage
Management:
1. Immediate admission to the hospital and seen by a surgeon
2. Surgery
-make a small incision over your scrotum
and untwist it.
- if found irreversibly damaged, they will take your consent to remove it.
- - will fix the other testes as well, as the chances of occuring in the other one has increased.
But don’t worry,
6 hours is the golden period. your testes may be saved.
- NPO .
- No Investigations required
- If one testes is removed, the other will provide fertility .
- Reassurance and empathy .
Positive findings of Testicular torsion
- Sudden onset of severe pain in the groin, 9/10 constant
- swelling of testis
- Very tender to touch
- High riding or horizontal lestis
- Phren’s sign - ve
- Cremestaric reflex - absent
