Patients with urinary tract stones commonly present with renal colic and the majority will pass the stone spontaneously. This depends on the size and the position of the stone, but most causing colic are under 5 mm in diameter.

Patients presenting with apparent renal colic need confirmation of the diagnosis.

MSU for haematuria and culture.

The patient with renal colic requires urgent analgesia. The traditional treatment for the pain has been Pethidine 100 mg by intramuscular injection. Oral Pethidine tablets are not usually adequate but Diclofenac 75 mg orally, or as a 100 mg suppository, can be a useful alternative. Note, however, that renal failure has been associated with the use of this drug. Those particularly at risk are patients with underlying renal disease, cirrhosis, congestive heart failure, the elderly, those taking diuretics and those with significant cardio vascular disease. It is contraindicated in patients with asthma and those taking ACE inhibitors.

Our recommendation, therefore, is to confine the use of Diclofenac to fit patients, under 55 years of age who are not on diuretics and to prescribe no more than 5 doses without further investigation

The stone should always be sent for chemical analysis if possible; the majority contain calcium oxalate, but it is important to identify the uric acid or cystine stones because medical treatment is available (and they do not show on plain X-rays). Please remember to tell the patient to pass urine into a receptacle.

The outline screening tests should include the following laboratory investigations :-

MSU, full blood picture, urea, creatinine, sodium, potassium, chloride, bicarbonate, uric acid, calcium and phosphate.

For stones that do not pass spontaneously.

There are four methods of managing upper urinary tract stones, either alone or in combination.

The new generation of ureteroscopes are of a fine diameter which has greatly facilitated their passage up a ureter. Ureteric stones can be visualised and removed with a basket or fragmented using lithotriptor probes.

May be associated with bladder outlet obstruction.

Particularly vulnerable group - immobile patients with long-term indwelling catheters. Those with persistent irritable bladder symptoms need a KUB X-ray.

Treatment - Endoscopic (a few need open surgery).

AFTER CARE/STONE PREVENTION (apart from specific treatment of underlying causes).

"Keep the urine dilute, ie., avoid producing deep coloured urine throughout the 24 hours, even if you have to get up once at night to empty your bladder."

Reduction of dietary calcium was thought to be helpful in preventing stones but excess of calcium in the gut combines with oxalate and is not absorbed. If calcium intake is reduced, more oxalate is absorbed and the resulting hyperoxaluria (particularly during the night hours) carries a greater risk of stone formation and hypercalciuria.

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The initial assessment of the patient should include a frequency and volume chart; the patient records the time and the volume of urine passed, together with any episodes of leakage that may occur over a period of 7 days. The number of incontinence pads used per day should also be recorded. During a 24 hour cycle, the normal individual passes urine between 4 and 8 times, with maximum volumes between 300 - 600 ml and a total output of 1200 - 1800 ml.

The frequent passage of small volumes of urine with urinary incontinence suggests either a bladder of small capacity or one that fails to empty completely. Reduced capacity may be due to habit (possibly from fear of incontinence), to hypersensitivity from infection or stones, to an unstable bladder from detrusor overactivity or to a contracted bladder from chronic inflammatory changes or carcinoma.

The bladder that fails to empty completely may be palpable if it is holding more than 300 ml, or it may be demonstrable on a plain X-ray or an ultrasound scan.

Urinary leakage with a normal bladder capacity suggests sphincter weakness as in stress incontinence, but urodynamic investigations may be necessary to confirm this. Urodynamic studies have a vital role in differentiating the various types of incontinence, namely stress, urge, overflow and reflex or neuropathic incontinence.

On the clinical examination, the option of taking a specimen of urine using a fine 12 or 14 FG disposable catheter should be given consideration when examining female patients. Patients handicapped by age, immobility, obesity etc cannot easily provide an MSU without a high risk of contamination and, in such cases, the report of bacteriuria with or without pyuria can be misleading. Examination of the urine is such a routine test, but the path report does need judicious interpretation.

Patients with urinary incontinence and a cystocoele usually require video-urodynamic studies before the correct course of management can be planned. Those with uterine prolapse are usually directed to the gynaecological clinic, but many elderly women have evidence of atrophic vaginitis which responds well to local oestrogen creams. These are best applied digitally rather than through a plastic introducer which can make them sore.

Obese patients should be advised about strict dieting. This is a therapeutic exercise as well as an essential preoperative requisite.

Please complete the confidential form  as accurately as possible.

Please note the time you pass your water and the volume passed. Any measuring jug will do for this purpose. Obviously when you are at work it may be inconvenient to measure the volume; in this case, record only the time. However, at other times please try to record both.

If you wet yourself at any time, record the time and underneath write the letter "W".

Day-time means when you are up; night-time means when you are in bed.

An example is provided below to help you :

AVERAGE DAILY FLUID INTAKE (in cups) = ______________________________

1. Each time you empty your bladder measure the volume in mls (millilitres) and write it in one of the hourly boxes (there is room to write several volumes in each box if necessary). You do not need to write the exact times. If you leak urine, write a W in the box.

2. Please mark the time you go to bed each night and get up for the day with a line across the space.

3. Record for ONE WEEK prior to your appointment.

4. Your chart that you bring to the clinic should look similar to the one illustrated below. It has a day filled in as an example.

5. You do not need to write down drinks unless the doctor has requested this.

Patients with frequency, urgency and urge incontinence form a large group of regular clinic attenders, and it is well worth introducing a trial of bladder training. The frequency and volume chart often shows that they can hold reasonable volumes of 300 ml urine or more at times, particularly during sleep; those who never hold more than 200 ml should be referred to hospital for further investigations. In the absence of any obvious abnormality on clinical examination 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 "by the clock", starting with an interval such as every two hours which can be managed without too much difficulty. This interval is gradually increased to two or three hours and the patient should keep a chart one day a week to monitor progress. A mild sedative at night can be useful particularly for those who wake at regular times during sleep to pass urine. An anticholinergic preparation such as Oxybutynin 2.5 mg can be used to support the training regime with 2 - 6 tablets a day; Propantheline bromide or Imipramine are alternative preparations.
If there is no response to such a trial, further investigations should be arranged.

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Long-term catheterisation is usually considered to be a "last resort" in the management of patients with loss of normal bladder control, but it should aim to improve their quality of life not to compromise it. Catheters introduce a high morbidity and the occasional mortality. All patients with long-term catheters will develop a chronic bacteriuria; infection arises at the rate of about 5 - 10% per day. Within 48 hours of introducing a catheter, a biofilm forms on the surface of the catheter as a fine fibrillar network from deposition of fibrin, desquamated urothelial cells and bacteria. The bacteria produce a glycocalyx from long chain polysaccharides which cause then to adhere to the surface of the catheter and these sessile bacteria are protected within the glycocalyx from the effect of antibiotics in contrast to the floating or planktonic bacteria in the urine. Antibiotics have a very limited place in the treatment of the chronic bacteriuria associated with long-term catheterisation; they are indicated when a patient develops evidence of a systemic infection or when the urine becomes particularly thick, murky or foul-smelling.

The complications of long-term catheterisation include:

• CATHETER BLOCKAGE
• BYPASSING OR LEAKAGE AROUND THE CATHETER
• CATHETER EXTRUSION
• STONE FORMATION
• INFECTIONS:
  • Epididymitis
  • Periurethral abscess
  • Septicaemia

The choice between a urethral or suprapubic catheter needs to be discussed with the patient. An important factor that influences this decision is whether or not the patient is sexually active; this subject must be addressed when considering long-term catheterisation for a disabled person.

Start with a small diameter catheter and inject only about 7 - 10mls into the balloon. Regarding the choice of material, the following is intended as a guide.

• PVC - for short term (7 - 19 days only)
• Teflon coated - 4 weeks
• Silicone - 12 weeks
• "Hydrogel" coated - 12 weeks
• Females - catheter length 22 cm / FG 12 - 16 / 7 - 10 ml of water in the balloon.
• Males - catheter length 34 cm / FG 14 - 18 / 7 - 10 ml of water in the balloon.

Store catheters in a cool, dry, dark environment; they tend to perish too rapidly!
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. If the patient is already taking a diuretic preparation, it can be helpful to take this at night when the urine output is normally reduced. It is advisable to make sure that the patient has a spare catheter of the correct size at home together with a catheter pack, local anaesthetic / lubricant etc, in the event of the catheter falling out from deflation of the balloon.

Patients with long-term catheters can be placed in two groups, namely those who block their catheters and those who do not. The reason for the high propensity of some patients to block their catheters is not understood. The "life" of a catheter varies from one patient to the next and can vary from two weeks to four months; each patient needs to be assessed individually regarding the frequency of catheter change. It is not justified to use an expensive silicone catheter if the catheter needs to be changed every 2 - 4 weeks.

When a catheter blocks, it should be removed and replaced by a new one, but a note should be made whether the catheter is heavily encrusted with debris or not. If the catheter becomes blocked at frequent intervals, consider the following points :

1. Has the patient developed bladder stones? A plain X-ray film (KUB) of the urinary tract should be performed to check whether there are any radio-opaque stones. If there is no evidence of stones, excessive debris may be a cause and a cystoscopy should be performed to clear this.
2. Make sure that there is free drainage from the catheter. The catheter or the tubing can become kinked, especially if inappropriate clothing is worn. Overweight female patients can occlude a urethral catheter.
3. Is the patient constipated? An impacted sigmoid colon or rectum can give rise to bladder spasms which obstruct free drainage of urine. An enema can be a very useful therapeutic measure under these circumstances.
4. If the catheter is heavily encrusted, send a urine specimen for culture and prescribe an appropriate antibiotic after changing the catheter. The culture willusually produce a heterogeneous growth of organisms.
5. Consider giving a course of allopurinol 100 mg tds to reduce the excretion of urates and calcium phosphates. Acidifying the urine with Ascorbic Acid Gm 1 tds is another measure to consider which might reduce the phosphatic debris in the bladder.
6. Bladder washouts are not recommended because they cause shedding of the urothelial cells. However, if the catheter is blocking frequently, regular washouts twice a week, or occasionally more often, are worthy of a trial. Urotainer Chlorhexidine, Suby-G or Saline may be used.

Bypassing of urine around and spontaneous extrusion of the catheter is commonly experienced in patients, particularly women, with neurological conditions such as Multiple Sclerosis. It 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. Anticholinergic preparations may be of benefit in these cases, and it is worthwhile trying a course of Propantheline Bromide or Oxybutynin. If 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 inadvertently, because the tract can close rapidly within 1 - 2 hours.

Patients with long-term catheters are "at risk" of infections because they carry a chronic bacteriuria. The infection can manifest itself in a variety of ways.

Epididymitis is not an uncommon complication of long-term catheterisation. It usually presents as a painful testicular swelling; it is important to continue antibiotic treatment in these cases for a period of at least six weeks to avoid an exacerbation which often follows a shorter course.

Periurethral abscess in male patients can present very serious consequences. Ulceration of the urethra can arise at the peno-scrotal junction, where the penis bends ventrally. The catheter should be strapped to the lower abdominal wall to prevent the urethral angulation at this point.

Septicaemia can present a serious threat to a debilitated patient and may arise after urethral instrumentation or change of catheter. A blood culture and IV antibiotics should be instituted without delay.

A wide range of products are available to attach to the catheter which enable the patient to feel comfortable and secure. Patients do require sympathetic, professional advice when they are first given a long-term indwelling catheter with details about the choices available to them regarding the drainage from the catheter. Whenever possible, they should be given the opportunity to try different products and to select the one they consider to be most appropriate to their needs.

Care should be taken to select the urine collection bag that is most suitable for the individual patient. Attention should be focused on the type of taps which are available on the bags for emptying and the ease with which they can be operated with one or two hands, avoiding any finger contamination. The actual capacity of the bags varies widely from 350ml to 2,000ml.

The link system refers to the linkage between the body-worn bag during the day and the night drainage bag. The purpose of the night bag is to provide undisturbed rest for the user who would otherwise need to empty the leg bag at intervals during the night. The link system is designed to reduce the risks of infection which had accompanied the previous practice of changing over the leg to the overnight urinary drainage system. A variety of link systems are available and no one type will be suitable for every patient in every circumstance.

Suspension systems provide a method of holding a body-worn urine collection bag in place under clothing and offer an alternative to leg straps. A variety of designs and sizes are available but most comprise of an arrangement of straps to secure the suspension system to the leg. As an alternative, the patient can try a suspension system that holds the bag on the leg in place, using either a net sleeve (Aquadry) or a sleeve from which the bag can be suspended from the waist.

The majority of manufacturers of urinary drainage bags provide their recommended fixation with the drainage bag, but some can be purchased from the respective company as a separate item to be used with a selection of bags. Choice of suspension systems will depend on the patient’s preference as well as careful assessment of the patient’s abilities combined with a trial of different types of suspension systems.

These devices have not been given an adequate test of time as yet. A catheter valve is connected to the outlet of the catheter allowing the user to empty the bladder when convenient and necessary, thus providing a more discreet alternative to urine drainage bags.

Catheter valves do demand a certain amount of manual dexterity and are not suitable for those patients who have lost normal bladder sensation. These valves are not as yet available on prescription.

Manufacturers produce useful handouts and guidelines for patients and staff on the subject of catheter management, usually free of charge. It is well worth obtaining a supply of these; each product varies in its use.

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THE PAINFUL SCROTUM

Epididymitis - Six weeks antibiotic treatment recommended. If it does not show signs of progressive resolution, think of Chlamydia and TB (but do not necessarily expect to find organisms in the urine).

Testicular tumour - also a possibility. Refer for ultrasound and consultation. Also, please let us know if you have patients with post-operative epididymitis (TURs etc).

Sperm granuloma - after vasectomy can masquerade as chronic epididymitis. Ultrasound and refer.

Acute orchitis - Mostly virus infection (usually mumps). Mumps orchitis occurs only after puberty and most are unilateral. Testicular atrophy may follow - advise referral and ultrasound (steroids rather than testicular decompression may reduce the chance of atrophy).

Note on testicular torsion - included here because differentiation from epididymitis and orchitis is not always easy, especially when the patient presents a little while after the event when local signs appear inflammatory. History is important and previous episodes of sudden pain with rapid resolution are not are not uncommon in testicular torsion. It can occur at any age, although 10 - 20 years is the commonest. It may also occur at any time including during sleep. If there is a possibility of torsion, send the patient to the nearest A & E Department by any means immediately and ’phone the urology or General Surgical Firm on take at the same time.

Torsion of the appendix testis (may be a visible/palpable bluish lump at the upper pole in the early stages) - same applies, we explore them immediately.

Longterm indwelling catheter users and those with urinary diversions - will all have organisms in the urine. Treat only if patient has symptoms.

Recurrent proven infection with bladder outlet obstruction. These patients usually require active treatment such as TURP or a urethral dilatation in an elderly woman. Should urinary infections persist despite eliminating residual urine as a possible cause, then it may be necessary to institute longterm low dose antibiotics. Experience has shown that it is best to rotate these low dose antibiotics, such as Ampicillin, Nitrofurantoin and Trimethoprim, on a monthly basis. If there is a persistent residual urine, and the outflow tract resistance has been lowered as far as possible, then intermittent self-catheterisation is a very effective way of ensuring the abolition of the residual urine and effective control of the symptoms.

Urethral syndrome. The symptoms of cystitis without MSU abnormalities in sexually active women is relatively common and often termed "urethral syndrome." A frequency volume chart will provide one objective measure of the symptoms. General advice, such as the self-help advice offered by Angela Kilmartin’s book "Understanding Cystitis" (available from most booksellers), should be the first line of management. Patients with persistent symptoms may be referred for consideration of cystoscopy and urethral dilatation which helps up to 40% of women.

Frequently recurrent cystitis in younger women with otherwise negative investigations. We recommend long term (six months or more) low dose antibiotic. In post menopausal women, not on HRT, check also for vaginitis which may respond to topical oestrogen cream application (without an applicator).

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HAEMATURIA

There is a poor correlation between the degree of haematuria and the severity of the underlying disorder. All patients with blood in the urine, whether macroscopic or persistent microscopic, should therefore be fully investigated to establish a cause.

Although there are many non malignant causes of haematuria, painless haematuria is the presenting symptom in 85 - 90% of urothelial tumours, whilst 10% to 15% have frequency and dysuria. Speed of referral and investigation is essential, since the outcome of treatment for invasive bladder tumours depends on the interval between the first symptom and first treatment. All patients are seen urgently at special haematuria clinics.

This is good for the detection of renal parenchyma tumours and larger bladder tumours, but is not suitable for the detection of urothelial tumours of the renal pelvis and ureter. Unless they are causing hydronephrosis or hydroureter a KUB will demonstrate most stones.

This is performed under local anaesthetic and is used as the initial diagnostic cystoscopy in order to speed the diagnosis e.g. at the Haematuria Clinic. Patients found to have a bladder tumour can then be given priority admission for resection of their tumour.

In the case of persistent microscopic haematuria, where the IVU and cystoscopy are negative, further investigation for possible glomerular disease is indicated. Attention should be paid to blood pressure, overall renal function, persistent proteinuria and urine microscopy for casts and dysmorphic red cells. Proteinuria in association with microscopic haematuria will direct attention to possible glomerular cause early in the investigation.

Blood in the seminal fluid, with either red or rusty coloured semen is uncommon, but an alarming symptom for the patient. It may occur as a single episode, recur over a period of time or be a persistent feature. It can originate from various sites in the genital tract and, in most cases, the cause is inflammatory and benign - almost invariably so in the under 40’s, whilst in the over 40’s the occasional malignancy (prostatic carcinoma, tumour at the bladder neck or very rare seminal vesical carcinoma) can present in this way. The approach therefore recommended is:

• Under 40s
  History, full examination including prostate and external genitalia. Investigate with an MSU before and after prostatic massage and with seminal fluid culture. Antibiotic treatment if infection or pyospermia found, using antibiotics which penetrate the prostate gland, such as Trimethoprim, Erythromycin Cephalosporins, or Ciprofloxacin.
  
• Over 40s
  In men over 40, and all ages with persistent haemospermia or associated haematuria, further investigation is indicated, including PSA and transrectal ultrasound to image the prostate and seminal vesicles (with guided biopsy if necessary). Referral to the Urology Clinic is merited for this latter group of patients.

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Both symptoms and benign enlargement of the prostate (BPE > 20g) are common (43% of men between 60 and 70 years of age - Garraway 1991) the symptoms are not necessarily related to the size of the prostate. The symptoms are not disease specific so PATIENTS REQUIRE OBJECTIVE ASSESSMENT TO ARRIVE AT A DIAGNOSIS AND FORMULATE ADVICE.

It is helpful to screen patients and identify those who require urgent referral. A general assessment, including intercurrent disease, mobility etc, is important, together with a dip-stick urine (with a follow-up MSU to the lab if necessary), abdominal examination, digital rectal examination (DRE) and a serum creatinine to exclude a UTI, chronic retention, obvious carcinoma and renal impairment respectively. WE DO NOT RECOMMEND THE ROUTINE MEASUREMENT OF SERUM PSA. However, patients often know about the test (though not its limitations), so the doctor should have a strategy for advising patients on the pros and cons of PSA testing (see below).

If no urgent reason to refer is found, the patient’s symptoms should be assessed in terms of their severity and bother. The key investigation in assessing symptoms is the Frequency Volume Chart (see page 9), which shows up inappropriate drinking patterns, maximal functional capacity of the bladder during the day and night and nocturnal polyuria (over 30% 24-hour urine output during the night hours).

Some hospitals offer a "full package" of initial investigations for males with urinary voiding problems at special flow clinics, and some practices are investing in flowmetry and bladder ultrasound as a primary care facility.

The diagnosis of Benign Prostatic Obstruction (BPO)

In the urology clinic urine flow studies are used to screen patients. If the maximum flow is <10 ml/s there is a 90% chance of prostatic obstruction. For flows >10ml/s, specificity is poor and more than one third of patients are unobstructed.

A rough guide to the likelihood of bladder outlet obstruction can be obtained by asking the patient to time voiding using a watch with a second-hand (average flow equals voided volume divided by time taken). The average flow should be assessed from 10 voids.

Pressure flow studies will be carried out if the flow rate is > 10 ml/s and interventional surgery is being contemplated.

Surgical prostate ablation by TURP or occasionally open prostatectomy is still the gold standard and produces the greatest measurable and long-term reduction in both symptoms and bladder outlet obstruction. Other methods of ablation (laser etc) are under trial. Pharmacotherapy may also improve symptoms by pharmacological action or placebo effect but, with a lesser measurable reduction both in symptoms and in obstruction.

Conservative treatment for mild or moderate symptoms.

A period of conservative treatment for three months is advised. This consists of bladder training, advice on fluid intake, pelvic floor exercises, plus or minus an anti-cholinergic drug, if the patient is thought to have detrusor instability (urge, urge incontinence). After discussion and reassurance, many men will adjust to mild or moderate symptoms in the absence of severe obstruction and some will experience spontaneous reduction in symptoms.

If conservative treatment fails and the patient wishes to have further treatment, both drug and surgical therapies should be discussed.

Drug Management

If the patient wishes to try drug therapy, an alpha-blocker is the first choice since its effect, if any, is immediate, but take care with the elderly and those on anti-hypertensives (hypotension and dizziness). Flow rates and post-void residuals should be re-measured at one month.

5-Alpha Reductase Inhibitors shrink only the epithelial part (25%) of the gland and take at least 6 months to achieve maximum affect. PSA MUST BE CHECKED PRIOR TO TREATMENT. (Note that they can also reduce serum PSA by half in benign and malignant prostate enlargement so if you have reason to check PSA in 5-alpha reductase treated patients, multiply the result by 2).

Check flow rates and post void residuals at 6 months and do not continue the therapy in the absence of significant subjective and objective benefit. These drugs are still on long-term trial and have, so far, been found to benefit a minority of men.

If drug therapy fails, or is not chosen, and the patient is sufficiently bothered, he should be referred for evaluation with a view to surgery.

Surgical Treatment for Persistent Moderate or Severe Symptoms

If symptoms persist and are troublesome, refer for evaluation for possible TURP or alternative prostate ablation. Symptomatic patients will have FR assessed and pressure-flow studies performed if necessary.

• Acute retention: If not referred to hospital initially, catheterisation at home and the arrangement for an urgent outpatient appointment is recommended. If the residual urine on catheterisation is > 1500ml, we would recommend immediate admission to hospital, since some of these patients will have impaired renal function and the subsequent diuresis may cause further complications of electrolyte balance.
• Chronic retention : If urea and electrolytes are within normal limits there is no need to catheterise immediately, but early referral is recommended.

Serum PSA - (normal up 4 ng/ml in the under 60s and up to 6ng/ml in the elderly)

THIS IS NOT A SPECIFIC TEST FOR PROSTATE CANCER but can be a pointer to the diagnosis and a rough staging guide after tissue diagnosis. It is a very useful monitor of treatment effectiveness, except for a minority of poorly differentiated tumours which may express PSA only at low levels. A PSA within the normal range for the majority of men does not exclude CaP.

WE RECOMMEND CHECKING SERUM PSA IN SYMPTOMATIC MEN ONLY ON CLINICAL SUSPICION OF PROSTATE CANCER, ie rapid progression of lower urinary tract symptoms (LUTS) in the absence of infection, suspect DRE – hard prostate/nodules/irregular shape, associated skeletal pain, family history.

WE DO NOT ADVISE ROUTINE POPULATION SCREENING as there are still uncertainties about management. A patient with or without LUTS requesting PSA should be fully informed about the interpretation and implications of the results before measurement. Many patients with lower abnormal results (between 4 and 20 ng/ml) will simply have benign disease - high results can occur in prostatitis. The diagnosis of CaP and its grade are made by transrectal ultrasound guided biopsies.

The Treatment of CaP

Localised Disease

Localised prostatic carcinoma diagnosed in men over 70 need not be a threat. 80% of such patients ultimately die of other causes (Johanson), but younger men and fit men in their 70s, with a life expectancy of > 10 years, risk life-threatening progression and may be suitable for, and wish to have, radical surgery. The treatment may therefore be selective, depending on age, intercurrent conditions and histological grading. Generally, in patients with a life expectancy of >10 years, our current recommendations for localised disease confirmed by careful staging procedures are :

• Well differentiated tumour: monitor PSA and DRE at 6 month intervals.
• Average differentiation : discuss and offer radical prostatectomy, if appropriate.
• Poor differentiation: micro-metastases may have already occurred and results of surgery may not be good. Radical radiotherapy is an alternative treatment. However, in such patients, all three options, watchful waiting, radical surgery or radiotherapy should be discussed.

Locally Advanced or Disseminated Disease

• In asymptomatic disseminated disease, hormonal treatment may be delayed without affecting longevity, but it is probable that tumour associated morbidity is less when hormonal treatment is initiated early.
• Patients with symptoms should be treated and extreme care should be taken in patients who develop back pain, since a small minority may develop cord compression leading to paraplegia. Long bones are also at risk from pathological fracture. A bone scan should be carried out on those in whom metastases are suspected.
• Two-thirds of patients will respond to hormone manipulation and the methods of manipulation should be discussed with the patient, ie surgical castration (bilateral orchidectomy), or medical castration.
• LHRH analogues are the best method of medical castration and a variety are now available. Since initial treatment causes increased testosterone levels associated with symptom flare, the patient should be started on Cyproterone Acetate three days before the first LHRH depot injection and continued on this for three weeks (300mg daily).Higher doses may lead to serious hepatic reactions. CPA may also be used as the treatment for hot flushes after orchidectomy or LHRH agonists (100mg daily) and in patients who have not responded to, or are intolerant of, other treatments (300mg daily). Liver function tests before and after treatment is initiated or when symptoms or signs suggestive of hepatic impairment develop are recommended.
• Monotherapy with Anti-androgens and combined treatment (total androgen blockade) are under investigation at present and are likely to be initiated from secondary care.
• Local radiotherapy to painful and otherwise unresponsive metastases is usually very helpful.

Please refer urgently to urology any man with prostate cancer who develops the following : - anuria, oliguria, renal failure (suspected ureteric obstruction), bilateral lower limb / bladder motor or sensory loss (suspected cord compression).

A rough guide to staging of histologically proven prostate cancer with PSA is as follows :

Poorly differentiated tumours can be under staged since they may express PSA poorly.

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Referral advised. Most scrotal swellings are benign and the commonest - epididymal cysts and hydroceles do not all need surgery. Young men are currently much more aware of testicular cancer and the emphasis in investigation now is :-

1. To exclude cancer.

2. To define the pathology.

History of trauma and previous surgery, including vasectomy, is important. Post-vasectomy patients may complain of pain and swelling (usually epididymal) often years after the operation. Testicular tumours are largely found in the under 50s.

Scrotal ultrasound is much more accurate than clinical examination in defining tumours and other pathologies. It is also of therapeutic value in reassuring many, so is now commonly used.

Any patient with a suspected testicular tumour is seen urgently.

• Intra-testicular lump
• When unable to distinguish whether lump is intra- or extra- testicular
• Painful scrotal conditions
• Impalpable testicle within hydrocoele of recent onset
• Post traumatic testicle - ? rupture / haematoma
• Malignancy suspected in palpably normal testicle

• Lump is clinically extra-testicular and testicle is normal

Regular specifically designated outpatient sessions for the further investigation and treatment of male erectile dysfunction are held in the Urology Outpatient Clinic at Southmead Hospital. They are staffed by a consultant, a senior urological trainee, a research fellow, a general practitioner (2 sessions/week) and an andrology nurse specialist. No special investigations are required before referral but a comprehensive list of any medication is helpful.

Patients with cardiovascular disease, often taking beta blockers and/or thiazide diuretics are the commonest organic group, followed by diabetics. After taking a history and physical examination the patient’s response to the intra-corporeal injection of a vaso active agent - papaverine, prostaglandin E1 or moxisylyte (Erecnos) - is assessed. If an erection is produced then the patient is offered tuition in self injection, or the intraurethral delivery system, MUSE, is considered as an option. If response is poor then vacuum constriction devices are discussed. Should these subsequently be tried and found unsatisfactory, then penile prostheses are considered. The younger non-responders who have no obvious underlying contributory causes are further investigated with colour Doppler duplex ultrasound scanning of the penile arteries, followed by dynamic pharmaco-cavernosometry. These investigations identify patients who may benefit from penile revascularisation or ‘venous leak’ surgery. Patients with Peyronie’s Disease are also seen in these clinics.

Urinary tract infections occur most commonly in young girls and are often of no great significance. They are best referred to one of the Paediatricians initially who will carry out routine investigations and will refer on any patients who have a surgical problem. Initial investigations include a plain X-ray of the abdomen and an ultrasound of the kidneys, ureters and bladder. Further investigations are only undertaken if the ultrasound is abnormal. Patients with recurrent infections will require a micturating cystourethrogram but, since this is such an unpleasant investigation in children, use is strictly limited.

In young girls with recurrent infections, daytime urgency and wetting is not infrequently associated due to bladder instability. These patients will require treatment for instability when the wetting becomes socially unacceptable.

The presence of an undescended testis should be picked up on the routine postnatal examination. Children should be referred for an opinion at approximately six weeks of age so that examination may be undertaken before the cremasteric reflex becomes active. Re-examination is undertaken at nine months of age and, if the testis remains undescended, surgery is normally undertaken between the ages of one and two years.

The foreskin, at birth, is normally adherent to the glans and is not retractile. As the child grows older, the prepuce would normally become more retractile, but the age at which this occurs is very variable. Not infrequently, children under the age of four will get recurrent bouts of balanitis which is symptomatically uncomfortable, but of no lasting harm. The foreskin is often normal and this is not an indication for circumcision. Patients rarely have a true phimosis under the age of four, and, with gentle manipulation, the foreskin can normally be partially retracted. If 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 xerotica obliterans affecting the foreskin in the older age group. Many patients have retractile foreskins but underlying preputial adhesions and, if by the age of eight or nine these preputial adhesions are still present, they can be freed by instilling Emla local anaesthetic cream under the foreskin for an hour. The adhesions may then be freed.

Enuresis is rarely a surgical problem and should be referred to an appropriate enuretic clinic. If there is a particular concern that the patient’s enuresis is secondary to another abnormality, a referral should then be undertaken, but such an underlying pathology is extremely rare.

Surgery normally advised at the age of 2 years.