An Approach To Common Urological Disorders PDF
An Approach To Common Urological Disorders PDF
An Approach To Common Urological Disorders PDF
Singapore
GONTENTS
2 List Of Contributors o4
11 An Approach to Haematospermia
21 Staff Profile 94
22 List of Sponsors 95
23 Notes 103
ir. :
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PREFAGE BY
THE EDITOR
It is with great pleasure that I pen this foreword. This book was
written in conjunction with the 25th anniversary celebrations o{ the
Department of Urology, Singapore General Hospital. Our department
was established in 1 988 by Professor Foo Keong Tatt. and is the first and
Iargest urology department in Singapore. ln the past quarter of a century,
we have challenged ourselves to be in the forefront of clinical setvice,
medical education and research. We also pride ourselves in being most
comprehensive, most specialised but the mosl approachable department!
Happy readingl
Dr Ng Lay Guat
Head and Senior Consultant
Department of Urology
5ingapore General Hospital
August 2013
',
Disclaimer
This book is intended {or educational purposes and not intended to replace
or substitute the advice o{ an expert professional.
i.
tsBN 98I-04-4206-8
llll
il PREFACE BY THE EDIIOR I AN APPROACH TO COMMON UROLOGICAT DISORDERS 3
I
,]..
2 LIST OF GONTRIBI'TORS 3 AN APPROACH TO BENIGN PROSTATIG HYPERPLASIA
AND LOWER URINARY TRAST SYMPTOMS
Professor Foo Keong Tatt
UROLOGISTS / NURSES FAMILY PHYSICIANS Emeritus Consu/tand Department of Urolog1q Singapore General Hospita/
Department o, Urology, SGH Department of Family Medicine
and Continuing care, sGH
Dr Ng Lay Guat INTRODUCTION
Head and Senior Consultant Dr Farhad Vasanwala
Consultant Although a common problem in urology, there are still gaps in our understandinq of the disease BPH.
Prof Foo Keong Tatt ln autopsy study of men, 50% above the age of 60 years had 8PH (1 ). Not all patients with BPH have
Emeritus Consultant Dr Ng Joo Ming Matthew LUTS and on the other hand, many patients with LUTS may not have BPH (2). ln our study on patients
Consultant with acute retention of urine due to BPH, 37.5% of them had only mild symptoms before the event (3).
A/P Weber Lau Kam On
Currently, with the widespread use o{ PSA testing in health screening, many patients with BPH present
Senior Consultant SingHealth Polyclinics
with a raised serum PSA. ln fact, only 23% of patients with raised PSA more than 4 ug/1, are due to
Dr Chong Tsung Wen Dr Gilbert Tan Choon Seng cancer on biopsy. The negative biopsies are due to BPH chronic prostatitis or a combination o{ both ( ).
Senior Consultant Directott SingHea lth Polycl i n ics Thus, the clinician would need to make the diagnosis to predict the course of the disease. anci then
Geylang decide orr the treatment for the individual patient in real life practice. To do these, understanding BPH
Dr Tan Yeh Hong
and its basic pathophysiology is important.
Senior Consultant Dr Hwang Siew Wai
Di rector, Si ng Health Polycl in ics
Dr Sim Hong Gee Bukit Merah
Senior Consultant
WHAT IS THE PATHOPHYSIOLOGY AND DEFINITION OF BPI{?
Dr How Choon How On histology, BPH is benign micronodular hyperplasia (5). The hyperplastic process is stimulated by
Dr John Yuen Shyi Peng Di rector, Si ng Health Polycl in i cs dihydrotestosterone (DHT). The micro-nodules coalesce together to form biqger nodules (prostate
Senior Consultant Sengkang adenoma). sinrilar to libroadenoma o{ the fernale breast. This occurs in the transitional and/or
Dr Henry Ho Sun Sien periurethral zones of the prostate, thus giving rise clinically to the laterai lobes and/or the middle lobe.
Dr luliana Bahadin
Consultant These cause obstruction by distortion of the funrreling bladder neck and compression to the prostatic
Directot SinqHealth Polyclinics
ttrethra. Distortron causes more obstruction than compression. The disease does nol af{ect an entire
Bedok
Dr Nor Azhari Bin Mohd Zam zone, but is focal in nature. ihere{ore, the degree o[ oLrstructron depends nrore on the site of the
Consultant Dr Koong Ying Leng Agnes adenoma, rather than the srze. For example, the adenorna situated right at the bladder oLrtlet beneath
Directoc Si ng H ealth Polycl inics the mucosa causes more obstruction, as compared to the one situated deeper in the stroma. Stromal
Dr Lee Fang Jann
Marine Parade adenoma would need to grow large enough to cause compression and significant obstruction. Thus this
Coneltant
explains why some small prostates can cause significant obstruction and some larger prostates do not.
Dr Peter Moey Kirm Seng
Dr Lee Lui Shiong
Directoti 5i ng H ealth Polycl in ics Therefore, cljnical BPH can be defined as prostate adenoma, irrespective of size. causing varying degree
Consultant
Pasir Ris of obstruction with or without symptoms (6).
Dr Allen Sim Soon Phang
Registrar
National University Health System
A/Professor Goh Lee Gan
HOW DO ! EVALUATE A PATIENT WITH SI.JSPECTED BPH?
Dr Valerie Gan Huei Li
Registrar
Professorial Fellow Division of Family Medicine, For patients with LUTS, it is important to exclude other causes such as diabetes mellitus (DM). nocturnal
University Medicine Cluster NUHS polyuria, urinary tract infection (UTl) and over active bladder (OAB) as may the case in female patients
Dr Kenneth Chen too. OAB can also be secondary to bladder outlet obstruction. It is important to identify this, and earlier
Resident
National Healthcare Group Polyclinics
treatment of bladder outlet obstruction leads to better chances of recovery. The development of urinary
Dr Tung Yew Chong frequency and urgency in a patient with BPH should raise the suspicion.
APN Juriyah Yatim
Head, National Healthcare Group Polyclinic
Senior Nurse Clinie-ian, A careful Digital Rectal Examinatron (DRE), revealing a firm and smooth prostate, and a normal serum
Toa Payoh
SGH Pelvic Floor Disorder Service prostate specific antigen (PSA) of less than 4 ug/L can rule out significant prostate cancer.
4 AN APPRoACH To COMMON UROTOGICA. DISORDERS I LIST OF CONTRIAUTONS AN APPROACH TO BtNI6N PROSTATIC HYPERPUSIA AND LOWSR URINARY TRAS SYMfrOMS I AN APPROACH TO COMMON UROLO6ICAL DISORDERS
{requency and nocturia. There are five possible responses to the questions, from "not at all" to "all In those presenting with acute retention of urine (ARU), the failure rate for trial off catheter is lower
the time", scoring from zero to 5. Therefore, the total score can vary from zero to a maximum of 35; in patients with grade 1 IPP at 36% compared with 69% rn patients with grade 3 IPP (14). Therefore,
0 to 7 constitutes mild symptoms, 8 to 20 as moderate and 21 to 35 as severe symptoms. patients in ARU who have grade 3 IPP would be better treated with surgery earlier, rather than have
repeated trials off catheter with conservative treatment.
Many international clinical guidelines still recommend the IPSS score as the main parameter for
choosing the modality of treatment. Patients with mild symptoms are watched, while those with For patients on non-surgical management, patients wrth grade 3 IPP were seven times more likely (than
moderate to severe symptoms are treated with alpha blockers, or together with 5 alpha reductase qride t tee) to deteriorate in symptom scores, or develop high PVR and ARU. With a follow up of 32
inhibitors (5 ARI'S). lf there ts no response to treatment, then more invasive procedures such as months, 49% of patients with grade 3 IPP deteriorated in the study. However, the other 51 % of grade
thermotherapy and transurethral surgery are offered (7). 3 IPP patients did not deteriorate, and therefore, there is also a risk of over-treatment if IPP was the sole
parameter used to decide treatment options (1 5).
However, the QOL score may be more important than the IPSS score. This consists of 7 responses: a
score of O ( feellng delighted), to the highest score of 6 (feeling terrible). Though some patients may HOW SHOULD TREATMENT OF BPH BE INDTVIDUALISED?
have high IPSS scores, they may not be bothered (low QOL scores). For example, a retiree may not Treatment should be based on whether BPH is affecting the function of the bladder or kidneys,
be bothered by getting up 4 times at night to void, as he might be able to get back to sleep. On the or causing bothersome symptoms to the patients. lf such is minimal risk, with no persistently hiqh PVR
other hand, a young executive would be bothered if he had to wake twice nightly, as it might affect and no bothersome symptoms, patients can be reassured and advised on fluid adjustments and healthy
his ability to work. lifestyle measures (exercise and diet).
Thus in our Ministry of Health guidelines, the treatment of BPH is tailored to the severity of the disease
Most patients with LUTS consult the doctor mainly to find out ii they have cancer, or if their symptoms (16). The severity can be staged according to the presence or absence of signrficant obstruction and
would affect the function of their kidneys. lf they can be rcassured, many would be happy to be bothersome symptoms (1 7).
watched, and accept the advice to adopt a healthy life style. To reassure them, apart from excluding
siqnificant prostate cancer, it is important to assess the extent of obstruction from existing prostate
adenoma. Severe obstruction by the adenoma would lead to dysfunction of the bladder and the kidneys. Significant obstruction is defined as persistent post void residual urine more than 1 00 mls, (or the
presence of a clinically palpable bladder). AIso, significant obstruction is suspected in patients who
persistently pass small quantities of urine less than 1 00 mls and have frequency and urgency,
EVALUATING OBSTRUCTIOt\{ indicating bladder overactivity.
This can be done in the Family Physician clinic tlrrough a detailed history of the urinary stream, such
as wlrether the stream can hit the wall of the urinal, or dribble between the legs. A more objective STAGING OF BPH
way for the clinician is to watclr the patient void and assess the flow visually, but this may be socially Stage l: Patients with no significant obstruction and no bothersome symptoms.
difficult. ln the specialist clinic, thc patient witlr a comfortably full bladder of about 200 to 300 mls They can be watched and counseled.
would have the srze and shape of the prostate assessed with trans-abdominal ultrasound (TAUS). The
patient is then asked to pass urine into the uroflourmetry machine, whrch would record the speed Stage ll: Patients with no significant obstruction but has bothersome symptoms.
of flow more objectively. For a proper flour test ideally, the volume voided should be more than 150 They would be considered for medical treatment.
mls. A f low rate of less than 1 0 ml/s would indicate obstruction 90% of the time (8). The other
Stage ll!: Patients with significant obstruction, irrespective of severity of symptoms would require active
10% of patients may have poor bladder contraciicns due to detrusor dysfunction from causes such
treatment with options of surgical intervention.
as diabetic cystopathy, rather than prostate obstruction. A flow rate o{ more than 1 5 ml/s would
probably indicate no obstruction. Stage lV: Paticnts with complications of BPH such as acute and chronic retention of uflne, recurrent
UTl, or gross haematuria, and bladder stone formation. They would generally need surgical intervention.
What is more important than flow rate is the assessment of the post void residual urine (PVR).
Persrstent post void residual urine o{ more than 100 mls would indicate that the voiding function
MED!dAL THERAPY
is affected and this may eventually affect the function of the kidneys from back pressure, such as
chronic retention of urine causing hydronephrosis (9). Such patients may have minimum symptoms There are two main groups of drugs used in treating BPH/LUTS:
*
(IPSS) but have enuresis. Though not common, it is important to exclude chronic retention by careful 1. AIpha blockers: such as Alfuzosin (Xatral), Terazosin (Hytrin), and Tamsulosin (Harnal). They relax
palpation and percussion for a distended bladder. ln the specialist clinic or if the family physician has the smooth muscles of the bladder neck and the prostate.
an ultrasound machine, the PVR can be easily measured. TAUS can also be used to assess the kidneys 2. 5 Alpha reductase inhibitors (sARl s): Frnasteride (Proscar) and Dutasteride (Avodart). They prevent
for hydronephrosis. lf the patient has persistent residual urine, or the presence of a percussible or the conversion of testosterone to dihydrotestosterone which stimulate the growth of BPH.
palpable bladder, he should be referred to the specialist clinic for treatment.
The alpha blockers are good only for symptomatic treatment. They have not been shown to prevent
Using TAUS, the size of the prostate can be estimated using the elliptical formula. the progression of the disease BPH (1 8).
The shape, represented by the lntravesical Prostatic Protrusion (lPP) can be measured from the inner
most protrusion down to the base of the prostate at the circumference of the bladder. (Fig 2)
Some alpha blockers claim to be more uro-selective than others, but would still cause postural
hypotension and giddiness in up ro 14% of patients (7). ThereJore, they should be given cautiously
IPP is graded accordingly: 5mm or less as grade 1, > 5mm to 1Omm as grade 2, and >lomm as grade 3 especially in elderly patients prone to falls. Although numerous studres have showed their effectiveness
in reducing the average IPSS, the percentage ol patient who benefited is still not well documented.
ln 2003, Chia SJ et al (1 0) showed that using pressure-flow studies, of patients with grade 1 IPB 79% Therefore, in patients who are bothered by their symptoms, the medication can be given a trial of
of them were not obstructed. Conversely, for grade 3 IPP patients, 94% of them were obstructed. not more than 2 to 4 weeks and then reassessed for response. lf patients find it effective with no side
This has been validated by other studres elsewhere (1 1), (12), (13) effects, then they can be prescribed for longer period of time.
6 AN APPROA'H TO UROTOGICAL DISORDERS I AN APPROACH TO BENIGN PROSTATIC HYPERPUSIA AND LOWER URINARY TRACT SYMPTOMS AN APPROACH TO BENIGN PROSTATIC HYPERPUSTA AND LOWER URINARY TRACT SYMPTOMS I AN APPROACH TO COMMON UROLOGICAI DISORDIRS 7
'OMMON
Recent studies by Park HY et al 20'l 2 have shown that the alpha blockers are more effective in Most patients are admitted on the day of surgery, and the length of stay is about 2 days. The
pataents with grade 1 than grade 3 IPP (19). complicatrons encountered include peri-operative bleeding. with the need {or re-interventictl at less than
2olo. Serious post-operative sepsis is less than 2% (24). Temporary incontinence rate is about 4 70 and
s-Alpha Reductase lnhibitors (5 ARI's) have been shown to rcdu.c the size of the prostate and the permanent incontinence less than 1%. The mortality rate is rare at less than 1%.
incidence o{ acute retention of urine (20).
On longer term follow up, urethral strictures and bladder neck stenosis may occur in 2 to 5% of patlents.
They are only effective for prostate more than 30 grams (clinically palpable large prostate). They are Recurrent prostate adenomata giving rise to recurrent symptoms and haematuria can be a problem, with 3
not effective for small glands. to 1 5% of patients requrring intervention in 5 years (25).
The 5 ARI's need to be taken for at least 3 months in duration,before any discernible effect is expected.
To reduce the problem of recurrent adenoma, Transurethral enucleation and resection of prostate
There{ore, patients need to be counseled on lifelong therapy. Thus the 5 ARls should generally be reserved (TUERP) has been introduced recently. (26)TUERP mimics open prostatectomy, enucleating the prostate
for patients with stage lll BPH and large prostate volumes more than 30 grams. The side effects include a adenoma endoscopically with the tip o{ the resectoscope sheath after {inding the correct plane. This
loss of libido, elaculation failure and erectile dys{unction in 1 0% o{ patients. A recent rcport by Roehrborn
removes the prostate adenoma more completely and can also better control penoperative bleeding.
et al (2'l) showed that combination therapy with an alpha blocker (tamsulosin) and 5 Alpha reductase Temporary incontinence rate is higher at aboul 14o/o (271.
inhibitor (dutasteride) is effective in reducing urinary symptoms and prostate size. and therefore, the
progression o{ BPH. However, the reported adverse events are also increased witlr combination therapy
(26% o{ patients), as compared to tamsulosin alone (15%) and dutasteride alone (9%). Therefore for Laser Prostatectomy: Holmium laser can be used to enucleate the prostate adenoma (Holep). This has
elderly patients, the combination therapy can still be prescribed but only after weighing the risks, benefits been done in other centres and widely reported, and have good long term results (28). TUERP essentially
and cost. lt may be useful in the subset of patients with bothersome symptoms and large prostate sizes does the same job withour the need for the laser, thus it is less expensive and more practical.
(more than 40 grams), who show good response to initial alpha blocker monotherapy with no side effects.
Laser vaporization: Green light laser is associated with less bleeding, but does not remove the prostate
to have less side effects than dutasteride (22) and is now cheaper in
Finasteride (Proscar) is said adenoma completely. The long term recui'rence rate is higher, and as high as 1B% of patients require
Sinqapore. However, the half-life of Proscar is 6 to 8 hours whereas dutasteride is about 5 weeks. re-operation in 12 months (29).
Therefore there may be less concern with using dutasteride especially when daily patient compliance
is difficult (7). Open Simple Prostatectomy is seldom per{ormed in Singapore, as it is more invasive with nrore post-
operative pain.
The 5 ARI's can reduce prostate size but cannot correct the shape of the prostate, which contributes
more significantly to obstruction. Tlrere{ore, in t)atrents with high grade IPP and small prostate One cornmon side effects of surgery is retrograde ejacrrlation in most patients after prostatectomy.
volumes, they may he better treated with surgery for high stage disease. Only a surgical option can Though not harmful, some patients find it less pleasurable during orgasm and can be distressful for
restore the prostate to its normal shape and configuration. them if not warned be{oreharrd. However, surgery should not cause erectile dysfunction, though it has
been reported to be about 4 to 5o/o.
SURGICAL THERAPY
Surgery would be indicated for patients with retention of urine (acute and chronrc), and those with . other minimally invasive procedures:
deterioration of symptoms not responding to medical treatment. A deterioration of IPSS (of 4 or Transurethral microwave thermotherapy (TUMT): TUMT had been used by our Department for ten
more points) and QOL scores suggest the possibility of OAB and bladder storage failure. Despite the years previously but it was found to be ineffective for the truly obstructing prostate. The recurrence rate
trend to treat these patients with anti-cholinergic agents such as oxybutynin (Ditropan), tolterodine was high and we have stopped using the procedure (30).
(Detrusitol) and solifenacin succinate (Vesicare), they may precipitate urinary retention and should be
used with caution. Transurethral needle ablation (TUNA) is still investigational.
lf OAB develops secondary to obstruction, the appropriate treatment should focus on relieving the Practical steps in the evaluation of LUTS/BPH at the Family Physician Clinic
obstruction (BPH) rather than treating symptoms. 1. Age: Clinical BPH usually occurs after the age of 45 to 50 years. ln the younger age group, a
urethral stricture should be considered as a possible differential diagnosis, and
Transurethrat resection o{ Prostate (TURP) is still the standard surgical treatmentlor prostate in the older age group, that of "aging bladder" and nocturnal polyuria.
adenomata causing signi{icant obstruction. The morbidity and mortality oI the procedure have been 2, IPSS and QOL scores: Although designed for self-administration, patients in our local context
reduced over the years with the development ol urology in Singapore. The biood trans{usion rate may need help from the nurse or physrcran. These scores give an idea of the severity of LUTS and
was reduced {rom 44% in the 1970 s to 4olo in the 1990's (23). Also, with the advancement of new the most bothersome symptoms. On follow up, these scores can give accurate documentation of
technology su(h as bipolar diathermy, TURP can be performed with normal saline for continuous patrents' progression or deterioration. The deterioration of symptoms especially frequency and
irrigatton during resection. This has elirninated the serious problem of TUR syndrome due to excessive urgency may indicate development oi OAB.
absorption of electrolyte solutions such as glycine or dextrose. This has also further reduced the 3. Palpate and percuss for a distended bladder: A clinically detectable bladder, immediately after
transfusion risk to existing rales ol 1Y" (24). urination, indicates significant residual urine. This is suspicious for significant obstruction, whrch would
need aggressive treatment and a referral to the urologist.
4. Observation of the voiding process: This would give an estimate of the flow rate and severity
of obstruction. The vcliding time can also be measured, and normal values are about 20 seconds.
8 AN APPROACH TO COMMON UROLOGICAL DISORDERS I AN APPROACH ]O BENIGN PROSTATIC HYPERPLASIA AND LOWER URTNARY TRACT SYMPTOMS AN APPROACH TO BENIGN PROSTATIC HYPENPLASIA AND LOWER URINARY TRACT SYMPTOMS I AN APPROACH TO COMMON UROTOGICAI. DISORDTRS 9
5. Digitai Rectal Examination (DRE) is important in differentiating BPH (which feels firm and ACKNOWLEDGEMENT
smooth) from malignancy (which feels hard and irregular). The positive predictive value of an Thanks to Dr Huang Honghong and Mr Norman Goh for assisting in editing the manuscript
abnormal DRE is 40olo, which is better than that of an elevated PSA level (above 4 uglLl al23o/o'
(4) DRE can also provide an esrimation of the prostate size, although it tends to underestimate the
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and cost-effectiveness in patient treatment
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AN APPROACI] TO COMMON UROLOGICAL DISORDERS I AN APPROACH TO BENIGN PROSTATIC HYPTRPLASIA AND LOWEN URINARY TRACT SYMPTOMS
I
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25 Rassweiler J et al. Complications of transurethral resection of the prostate (TURP) - incidence,
management, and prevention. Eur Urol. 2006; 50: 969.
t6. Llu C et al. Transurethral enucleation and resection of prostate in patients with Benign Prostatic
Hyperplasia by Plasma Kinetics. J Urol. 2010; 184,2440-2445.
21 Zhang KY et al . Bipolar plasmakinetic transurethral resection of the prostate vs. transurethral
enucleation and resaiction of the prostate: pre- postoperative comparison of parameters used in No ctinicatly detected bl.adder
assessing benign prostatrc enlargement. Singapore Med J. 20'l 1 ; 52(1 0): 7 47 -751 .
26. Neill MG et al. Randomized trial comparing holmium laser enucleation of prostate with
plasmakinetic enucleation of prostate for treatrnent of benign prostatic hyperplasia. Urology.
2006;68(5): 1020-4.
29. Horasanli K et al. Photoselective Potassium Titanyl Phosphate (KTP) Laser Vaporlsation
Versus Transurethral Resesction of the Prostate for Prostate larqer than 70 mls: A short-term
prospective randomized trial. Urology. 7OO8; 7 1 (2) 247.-251 .
30 Lee KT et al. Transurethral microwave thermotherapy (TUMT) for benign prostatic hyperplasia
(BPH) - Our First 1 00 Cases. SMJ. 1 995; 36: 1 81 -1 84.
31. Wang D et al. Staging of benign prostate hyperplasia is helpful in patients with lower urinary
No Bothersome Symptoms Bothersome Symptoms
tract symptoms suggestive of benign prostate hyperplasia. Ann Acad Med Singapore. 20'10;
39:798-802. 00L less than 3 QOL more than 3
Watch and
Smat[ prostate Patpabte [arge prostate
cou nseI
IMore than 30 to 40 grams)
,*.*"*[-*-.-
I
&"
Figure 2. Transabdominal ultrasound measurements of intravesical prostatic protrusion (lPP)
Figure 1. tPSS & QOL score sheet
2 3 /. 5
5. How often have you had weak urinary stream? 0 1
0 2 ?, 5
4. E6E.flFET6Eefffi$*?
s. E6€ffi4i*rflII'.*? 0
--- 2 3 4
4
Prostate Votume: 24 mls Prostate Votume: 38 mts
6. E6#EH r&{FSn *lr#.hlB? 0 l 2 3
4X s)i
IPP Grade 2: 9mm IPP Grade 3: 17 mm
7. U,\riESrl+fre-rsm*E*frtr,EnX? isa r)i 2;x 3,t
frfiEi+a=
Grade 1 IPP: < 5mm
Grade 2 IPP: > 5 - 10 mm
ti66ErES(aoL)i+,}*
Grade 3 IPP: >10mm
iffiE i9ifr.E iIEIT)( zirk;fiH tqifi fRig
ANAPPROACHTOBENIGNPROSTATICHYPERPLASIAANDLOWERURINARYTRACTSYMPTOMS
14 AN APPROACH TO COMMON UROLOGICAT DISORDERS I AN APPROACH IO BENIGN PROSTATIC HYPERPUSIA AND LOWER URINARY TRACT SYMPTOMS IANAPPROACHTOCOMMONUROLOGICALDISORDERS 15
AN APPROACH rO BPH: A FAMILY PHYSICIAN'S PERSPE0TIUE 4 AN APPROACH TO NOGTURIA
Dr How Ghoon How Dr Ng Lay Guat
Director and Famity Physician, Senior Consultant, Head and Senior Consu/tant Depaftment of Uro/ogy, Singapore General Hospital
SingHealth Polyclinics, Sengkang Polyclinic
WHAT IS NOCTURIA?
INTRODUCTION Nocturia is defined by the lnternational Continence Society (lCS) as'waking up at night to void'(1) and
Benign prostatic hypertrophy (BPH) is commonly faced by older men in our community. As the li{e night is defined as 'the period of time of going to bed with an intention to sleep. to waking wrth an
expectanCy of men rn Singapore Continues tO rise, we can expect a higher prevalence of patients intention to rise regardless of when this period occurs'. This symptom appears to be present in both
presenting with lower urinary tract symptoms due to BPH. gender and progressively more common with age. Holever, the level of bothersomeness is worse for
the younger age group (2).
Many asymptomatic men may have been previously diagnosed with BPH after being evaluated {or
a raised prostate specific antigen (PSA) level during routine health screening. The U.S. Preventive This condition is a common symptom and can also be a major cause of bother to the patient in terms of
Services Task Force (USPTF) updated their recommendations in 2008 to discourage the routine use of sleep quality, day time sleepiness and overall detrimental impact on healllr and economy. Direct ill effects
PSA screening for prostate cancer in younger men. This should lead to a corresponding decrease in of nocturia include depression, daytime somnolence and reduction in productivity. ln the elderly, there is
the diagnosis of asynrptofi\atic men with early BPl l. an increased risk of falls, fractures and its subsequent morbidity and mortality (3).
Our current clinical practice guidelines recommend individualised treattrent of BPH based on the HOW DO WE EVALUATE A PATIENT WITH NOCTURIA?
severity of urinary obstruction and bothersome symptoms. The lnternational Prostete symptoms There are rnany causes of nocturia and spans across multiple disciplines. The optimal management
Score (tpSS) and the Quality of life (QOL) questionnaire allow family physicians to per{orm a severity at the primary care level relies on the ability to identify the causes, and channel patients to the
assessment easily and monitor these patients over time. Between the two measures, clinicians should appropriate disciplines.
pre{erentially use the QOL score as it re{lects how the individual's life is affected, regardless of the
severity of storage cr voiding symptoms reported. The key with history taking involves clarifyinq if the symptoms are purely nocturnal or global. Details
such as insomnie, sleeping habits and whether the wakening was due to urgency or for other reasons
ln a situation where the clinical condition is complicated (such as renal impairment from BPH, or will aid in the differential diagnoses. History of snoring or apnea from the spouse is important in
suspected concomitant urological malignancies), the Family Physician may co-manage their patients the diagnosis of possible obstructive sleep apnea. Also medical history such as that of congestive
with a urologist. Those with mild BPH can usually be managed in the community with regular heart disease, diabetes mellitus, renal rmpairment, varicose veins, obesity etc are impor[ant. Detailed
monitorinq and titration of oral medications. They should be re{erred to their attending urologist to assessment of lower urinary tract syrnptoms rs a n]ust.
discuss surgical options when there is disease progression. ln this way, the maiority of patients wlth
BPH can be managed at the community level. Physical examination invohres assessment of the patients BMl, targeted examination of the lower limbs
to assess for lower lin-rb edema, and presence o{ varicose vcins. Other assessment rncludes examination
of the bladder, prostate and in females, a detailed vaginal examination.
The management of nocturia anchors mainly on the patient's quality of life and the risks of further
morbidity and mortality. The most important tool is that of a bladder diary (4). This is a 3 day self
reported diary where patient or caregiver records the patjents intake in terms of beverage type, volume
and time and voiding habits (voided volume, time of void and associated symptoms of urgency and
incontinence). Figure 1 below shows a typical voiding diary and figure 2 shows a typical diary of a
patient with nocturia. Note the significant amount of urine produced between midnight and 7am
(sleeping iinre).
The voiding diary is the most reliable tool to differentiate between those with small bladder capacities
(leading to global urinary frequency), nocturnal polyuria (nocturnal urine outilut is >30% of totai 24
hour urine output). polyuria or mixed symptoms.
CONTINENCE NURSE
E!ts
tvi), wlT
En tbt llr Bd lE-l $1 timi
l0'lbu t h0u- lc'\t)a L0oL L
Luta l0x
Tr?es ofrlsrdi bke.
IOD{,L l l.\t l LL(iC 1,tr )oo<t
I );h iv I tl, Ll, I ).!0 , It0Q E.t( lo t,
).lttn ll|LL ltfr L
q-t( lo cr-
?.Voa t nlL )u(i IEoLL n-x \7)LL
V'k( i^ kot.t, V'-6 n ll0c-L r),u loocL
PU Bnge:
tr'j 0n(- >.{4) t00(*
k.to^ IhD/ L t\tt lDo(L
la,qn tDbu, dl;r loccL fvo l)a( L
Iri? l\De 5oc- Jlw lloci-
)'fi* luurt- 1ot. l'Vr I )occ
;+.t{t lta cL lt.la J-0 c; V.r,o IOLL
.fr( Ito Lu l-Yor. .lr11l l9ot t 1-x tto(L
Nocturia:
tnr€ryal tie
Lo* k'toa looL Iu* 'au-
I
$t tt
rl
; 18 AN APPROACH TO CON1M1ON UROLOGICAL DISORDERS I AN APPROACH TO NOCIURIA AN APPROACH TO NOCURIA I AN APPROACH TO COMMON UROLOGICAT DISORDERS 19
l
Figure 1. Typical voiding diary detailing intake and output WHAT CONDITIONS MAY MIMIC NOCTURIA?
Small bladder capacity
The cause o{ srnall bladder capacity whether global or nocturnal is usually urological. This may be due
to problems of bladder outlet obstruction, causing high post void residual urine. Other problems rnclude
NOCTURIA an overadive bladder, neurogenic bladder, or structurally contracted bladders due to urinary tuberculosis
or radiation therapy. Other forms of irritation to the bladder such as bladder or ureteric calculi, bladder
tumours etc can also lead to similar symptoms. These patients are best referred to the urologists for
further assessment.
Frequency-vo[ume chart
Nocturnal polyuria
Nocturnal polyuria is defined as passing more than 20-30% of his total 24 hours urine output in the
night. The normal nocturnal urine output ratio in young patients is about 20% and for the elderly, up to
3070 is acceptable. The causes of nocturnal polyuria are listed in the figure 3. Medical conditions leading
to fluid retention or peripheral edema, such as congestive cardiac farlure, result in increased intravascular
Low NBC l<200 mt
NocturnaI polyuria: Potyuria: 24-h volume when patients assume a recumbent position in the night. Obstructjve sleep apnea can cause
NPi ,33% votume ,40 mt/kg
or NBC| >21 q nocturnal polyuria from increased intrathoracic pressure and increased secretion of the atrial natriuretic
Low GBC hormone from the right atrium. This, in turn, leads to diuresis and nocturnal polyuria. lt is noteworthy
{MW <200 mt) that snoring alone is not diagnostic of OSA.
Overnight water M uLtipte
d eprivati on incrementaL ln other situations, the elderly may have nocturnal polyuria that occurs spontaneously, in the absence of
aetioLogies as CCF. DM or OSA. This is attributed to the loss of the usual circadian secretion of anti diuretic horrnone
per individuaI at night. As a result, the elderly individual produces relatively more urine in the evening and night.
Congestive unne >800 urine <800 nocturia
heart faiture m0sm/kg m0sm/kg categ ori es Polyuria
Occasronally, nc,cturia may be due to polyuria, ie producing more than 40 ml of urine per kg body
Primary RenaI werght per day. Causes o{ polyuria may be attributed to poorly controlled diabetes mellitus, diabetes
poLydipsia co nce ntra tin g
insipidus (Dl), primary polydipsia or poor renal concentrating capacity (nephrogenic Dl). The optimal
Look for urotogicaI treatment of each condition is specialised and bevond the intention of this article.
capacity text
causeS:
. prostatic obstruction HOW SHOULD ITREAT PATIENTS WITH NOCTURIA?
. nocturnaI detrusor Behavioial changes
ove ra ctivity A reduction in consumption oI caffeinated beverages such as cof{ee or tea at night and a reduction in
. neurogenic btadder water consumplion 2 hours before bedtime helps to decrease nocturnal diuresis. The eievation of lower
. parmacotogic limbs and using undergarments with graduated compression help to mobilise peripheral fluid to reduce
ag e nts Dx centraI Dx nephrogenic diuresis at night in the supine position.
. bLadder/ureteric diabetes diabetes
calcu Ii insipidus insipidus Medical therapy
Usage of sleep medications may be iridicated especially if the nocturia occurs as a result of poor sleep
Excessive PM or insomnia.
Chronic renal
ftuid intake faiture, [ithium,
Usage of diuretics in the presence of peripheral edema may help alleviate the situation. Commonly
tetracyc Ii ne,
0 bstru ctive {urosemide is used in the mid afternoon, to clear the fluid accumulated through the day. However, they
hyperca [ce n ia
s[eep apnoea should not be taken in the late evening, otherwise. the late onset of diurasis worsens nocturnal polyuria.
hypokalemia
su spected However, this regime is frequently difficult to manage as the individual rate of absorption of frusemide is
Isn ori ng, unpredictable.
obesity,
short neck) Specific treatment of nocturnal polyuria is the use of desmopressin (5), which is a synthetic analogue of
AVP This is a selective V2 (vassopressin) receptor agonjst with less uterotonic effects. Several randomized
controlled trials have shown good efficacy of desmopressin on nocturia. The main effect is to reduce
the urine output by water reabsorption, hence reducing the need to void. This in turn improves the
Abbreviations: NBC - nocturnal blabber capacity; NBCi - nocturnal blabber capacity index; time to first void and quality of life. Potentially serious side effect of hyponatraemia results Irom serum
NPi - noctunal polyuria index; MW = Maximum voided volume; mOsm/kg = osmolality dilution o{ sodium. Hence desmopre;sin is currently not indicated for patients more than 65 years. lt is
GBC - global bladder capacity recommended that sodium levels be taken at baseline, and soon after starting treatnrent, and regularly
thereafter. Patients should be educated on symptoms and signs of hyponatraemia and instructed to stop
Source: The New England Research institutes, lnc. (NERI) Nocturia advisory conference 201 2:focus on the medication rf that occurs.
outcomes of therapy. BJU lnt 2013 (4)
20 AN AppRoACH To coMMoN uRotoctcAt- DlsoRDERs I aN AppRoACH To NocruRtA AN APPROACH TO NOCTUiIA I AN APPROACH TO COMMON UROTOGICAT Di9ORDERS 21
other medical therapies suitable for treatment at primary health
level also includes treatment with AN APPROAGH TO NOGIURIA: A FAMILV PHY$ICIAN'S
both day and niqht, ie
,ntiit,otin"rgl.r. This is useful for patients with problems of urinary frequency PERSPE TIUE
overactive bladder.
Dr Tan Hsien Yung David
people of both gender and all ages .
ln summary, nocturia is a common condition that occurs in Family Physician.Assoc,ate Consultant & Deputy Head, Jurong Polyclinic
the Various causes of
Management stems on patient,s bladder diary, which helps to differenliate Ass,stanf Director, Family Medicine Development Division,
with
no.triu. Due to the multifactorial causes, diiease pattern differentiation and co-management National Healthcare Group Polyclinics
the primary care physician allows streamlininq of management
Nocturia is a common cause of sleep distr,rrbance amongst the adult population witlr a rising prevalence
REFERENCES with age. lt usually affects more females in the younger age group, but the prevalence in men catches
,1'VanKerrebroeck,PAbrams,PChaikineta|.TheStandardisationofterminologyinnocturia: up in older age groups.
Red flags not to be missed: Chronic renal failure, Congestive Cardiac Failure, Liver Failure, Prostate/
Bladder Cancer
often missed (pitfalls): Drugs, Diabetes lnsipidus, obsiructive Sleep Apnoea, Urinary Retention,
Calcuii/Cystitis
lnvestigations that can be perfonned in the primary care setting include urine analysis, and ascertaining
serurn electrolytes,creatinine, blood glucose and prostate specific antigen levels (if clinically relevant). A
bladder diary while inconvenient. may be of value if the patient is compliant and motivated.
Once serious conditions have been excluded, a trial of behavioural change or medical therapy as
previously described niay be initiated and the patient closely followed up {or response to treatment. lf
there is no improvement over a reasonable amount of time, the &tient should be referred to a specialist
for further evaluation.
Physical examination
1. General appearance: Body mass index
2. Abdominalexamination
3. Vaginal examination: atrophic vaginitis, presence of cystocoele/urethrocoele,/rectocoele. pelvic floor
sirength assessment using the Oxford scale, Q-tip test to look for urethral hypermobility, cough test
(supine and standing) to demonstrate 5UI
4. Digital rectal examination: prostate size and consistency, rectal masses, anal tone
5. Consider neurological examination especially in overflow incontinence or suspicion o{ spinal disorder
24 AN APPRoACH To coMMoN UROLoGICAL DISoRDERS I AN APPROACH TO URINARY INCONTINENCT AN APPROACH TO URINARY INCONTINENCT IAN APPROACH TOCOMMON UROTOGICAL DIsORDERS 25
ti
WHEN WOULD YOU REFER YOUR PATIENT WITH URINARY Urea, electrolytes, creatinine, glucose and urinalysis are simple laboratory investigations that can be
INCONTINENCE TO AN UROLOGIST? performed in the clinic. Creatinine level may be elevated if there is urinary retention secondary to
When an underlying urological disease is suspected bladder outlet obstruction or denervation of the detrusor Urinalysis should be obtained to rule out
lf the patient has stones, especially if it is causing urinary tract obstruction, a
referral should be made'
haematuria, proteinuria, glycosuria and infection. lf a bladder scanner is available a PVRU should be
inu pu,i.nt should also Ue ieferred {or a cystoscopy or further imaging if malignancy is suspected. obtained. A PVRU of greater than 200m1 is suggestive of overflow as a main contributing cause of the
treated in tanderr witlt
Coniplex infections e.g. tuberculosis of the genitourinary tract should also be incontinence.
pyuria.
an iniectious disease physician. This may be suspected if the patient has sterile
@
population profiles in these studies result in wide-range prevalence of AMH. The widespread f) History of pelvic irradiation
diagnostic screening for microscopic haematuria at primary healthcare settings has resulted in large g) History of occupational exposure to chemicals or
dyes
number of patients re{erred to tertiary institutions for further evaluation. (benzenes or aromatic amines)
HOW IS MICROSCOPIC HAEMATURIA DEFINED? W_!AT DO UROLOGISTS DO FOR TI-IE EVALUATION OF PATIENTS
REFERRED WITI-I MH?
Microscopic haematuria 6VH) is d"iinud as the presence of three or more red blood cells (>3 RBC) per
high-power field (HPF) in a fresh and properly collected mid-stream urine sample under microscopic We are guided by the American LJrological Association (AUA) gujdeline on the evaluation
AMH (3) However. the optlmal evaluaiion of these patients of patients with
examinatron (2), (3). is controversjal. This is reflected by ,Lhe fact
However. the caveats are: that out of the I 9 statements on the AUA guideline,
t 1 werl ,ecommendations basecj on evidence
grade C, whire the remaining 8 statements
i. MH is detected by urinary microscopy, and not by a dipstick test that detects heme, thus grving were based on either expert
irincipte.: rn
rise to false positive results in the presence o{ myoglobinuria or haemoglobinuna
singapore' we are also guided on this aspect
by the lvrinistrf of t leaith clinical "-i"i.ig;ijetiner
"piri""practice
ana
our local experience on the evaluation patients'with '
' ii. The urine specimen should be freshly collected as {ormed elements (such as cells and casts)
AMH.
degenerate and bacteria may overgrow at room temperature suffice to, say tl rat the urological assessment o1 lr,4H
rnvolves a detailed history, physical exanlination
iii. The urine specimen should be a clean catch, mid-stream urine sample, so that contarrirratiorr follonred by imaginq evaluation oi the upper (kidn"y,
ur"t.o) and lower (bladder and urethra)
the "na
by skin, vaqinal cells, bacteria arrd protein-containinq secretions is minimised. urinary lracts However, most patients referred for
evaluation of AIvIH has incomplete or inadequate
primary evaluation that may require
the urorogists to ,"qr.riio, UFEME or upc. The
subsequent urological evaluations depends on-risk comprexity of
IS SOME DEGREE OF MH CONSIDERED NORMAL? stratlircaiion of patients for urological disease.
primary aim is to exclude urological malignancies, The
in partiiular urothelial malignancy. For patients
of Mll is normal. such that 1-J
The above definition implies that some deqree RBC/HPF on low risk factors for urorogical disease with
.
1ag-e so vur", non-*oker, no history of gross haematuria,
microscopic examination is considered acceptable. urological disease or symptoms) an upper urinary
tract irnaginq witn an ultrasound kidneys and bladder.
a KUB.x-ray to detect urinary stone, with or without
urinar/cyiology are sufficient to rule out seriolrs
I5 SCREENING FOR MH RECOMMENDED? urological underlying causes in most cases. For patients
wiih risk factors for urological disease (age >
Routine screening of asymptomatic population for MH is not recommended (Clinical Practice 50 years, high RBC count on UFEME, smoker, hLtory
of painress gross haematurial irrrtative urologicar
Guidelines on Glomerulonephritis, Ministry of Health 5ingapore ZOOT ,2 The US Preventive Services symp-toms). an upper urinary tract imaging of
highei sensitivity i.e. cr urography wi*, conirasi totto*
by a flexible cystoscopy examination miy be
Task Force,4 The Canadian Task Force on the Periodic Health Examination5). However, our MOH wairanted. rt is sJirice to ruyir,ui., ir-.,"r" i"r.r,iqr,,""r.*
costly arrd not entirely risk{ree (radiological contrast
guideline states that dipstick examination is recommended for those who are at risk for renal diseases ,"y oe nepr,rotoxrc and may cause allergic reaction),
for the purposes of detectrng proteinuria or AMH.(2) and rather invasive (frexible cystoscopy), orrry serect patrents
wiiir nigh", ,ir[iu.i;, i", i,n",iL*
urologrcal disease or marignancy undergo cr
urography and frexibre cystoscopy in our centre.
especially so for indication of frexibre cystoscopy This is
IF MH 15 DETECTED, IS 1T ALWAYS CLINICALLY SIGNIFICANT? us ti,eir,unc" of finding any urorogicar
abnormarity is
low when this is performed for the indlcation
MH is probably not clinically significant, if the diagnostic test was carried out during or soon after:
oi AMH.
menstruation, vigorous exercise, sexual activity. viral illness, trauma, infections (i.e. recent UTI) WHAT ARE THE CHANCES OF FINDING UROTHELIAL
or recent urological instrumentation. Under these circumstances, one is recommended to repeat MATIGNANCY ON
FLEXIBLE CYST'OSCOPY FOR MH?
an UFEME (urine full examination and microscopic examination) in a {ew weeks' time following
appropriate treatment, e.g. treatment oI UTl. As alluded to above, it is common practice in
Urology centre that only patients with known
for r:rologicar disease were sereded to unaerqo risk factors
fle;bte ;rior.opy. Thus, 85% of patients who undergo
I NEED TO REFER PATIENTS WITH AMH TO HOSPITAL, WHICH SPECIALTY flexiblecystoscopyinurologycentreareolde"rthansov"r."ro
lnaretrospectivestudyof .1200 1exible
(NEPHROLOGY OR UROLOGY) SHOULD THE PATIENT BE REFERRED TO? cystoscopy performed for the evar.uation of AMH
after negative upper tract imaging over a 1g-year
period in the Urotoqy Centre, 90.i%
This would depend on one's clinical suspicion o{ whether the cause of MH is a medical (e.9.
of the cystoscopy
0 6% of patients were found to have urotheriar
fi"i;;q;;.r; .;;ii;;;;i;;;Jd;). o"t,
glomerulonephritis) or a surgical (e.9. urinary stone, malignancy) one; please refer to AMH Evaluation ,urignun.f ot'ir," bradder. of those with abnormar
findings (- 9% of totar cohort) had benign
Algorithm below. One can infer Irom the parameters in the UFEME, urine phase contrast (uPC) and cautes iniruJingiysrtis, sma, urinary stones). we
conclude that the yield of flexible cystoscopy can
clinical factors in order to decide whom the patients should be referred to. in detecting ,"orogi.ur malignancies in patients
the,evaluation of AMH is very row. Therefore, referred for
malignancies such as bradder cancer. rn fact.
,.ru"ninf il. arrrH is not a usefur way to detect urotherial
screening for trrrH has not been shown to have
ln general, patients should ideally be evaluated by a nephrologist if; uFEME shows significant on the overall prognosis of patients with urothelial any impact
proteinuria; uPC shows dysmorphic RBC and red cell casts; and there are sign:, of renal impairment caicer (o), (7), (8). Most bladder cancers detected in
the urology clinic are superficiar cancers and have good
and an elevated serum creatinine level (patients with renal impairment or risk factors predisposing a progn*o in the absence of screening.
AN APPROACH TO COMMON UROLOGICAT DISORDERS I AN APPROACH TO ASYMPTOMATIC MICROSCOPIC HAIMATURiA (AMH) aN aPPRoAcH To ASYMPTOMATI. MlcRoscoPlc
HAEMATuRIa (AMH) I AN APPRoA.H ro coMMoN u,olocrcAt DrsoRDeRs 29
AMH EVALUATION ALGORITHM
TAKE HOME MESSAGES:
a) MHisdefinedasthepresenceot>3RBC/HPFundermicroscopy.Thus,somedegreeofMH(1-3
RBC/HPF) is considered normal.
b) MH is detected by urinary microscopy, not dipstick'
c) AMH is common.
is essential'
d) Fresh, properly collected mid-stream urinary specimen
or soon after: menstruation' vigorous exercise'
e) Repeat uFEME i{ urine specimen collected during
sexual activity, viral illness, trauma, infection(i
e recent UTI)'
is not recommended'
f) Screening of asymptomatic population for MH lnitiaI assessment by
history & physicaL
9)Referraltonephrologistsisindicatedifthereispresenceof:proteinuria'dysmorphicRBCorred
cell cast, renal lmPdilment' examination for other
by
The detection of urclogical malignancy a{ter full
urologicalevatuations including upper imaging potentiaI causes [e.g.
h)
aniti"'iUt" tyttottopy is iow for AMH The complexity of
urological
ultrasound or Ct urograpny Repeat UFEME after i nfecti on,
should be calibrated according to
investigations by CT imaging and / or flextle cystoscopy treatment of other menstruation, recent
pattent's rlsk factors for urological malignancy' cause{s) e.g. infection urologicaI procedures,
*Type of imaging
for MH is not a recommended screening test for urothelial
malignancies'
i) Screening trauma, viraI ittness,
sexuaI activityl depends on c[inicaI
REFERENCES suspicion of
of asymptoma[ic adults {or urinary tract underlying urotogicaI
1. Woolhandler S et al. Dipsilck urinalysis screenlng No further conditions and risk
disorders. l. Hematuria and proteinuria JAMA 1989;262:1214-9'
Glomerulonephritls 2007' investigation factors (e.g. history
2. Ministry of Health, Singapore Clinical Practice Guidelines - PotentiaI renaI causes
{ollow-up of asymptomatic microhaematuria (AMH) in Ie.9. significant of smoking, gross
3. Davis R et al. Diagnosis, evaluation and
haematuria, age>50,
adults: AUA guideline. 2012' proteinu ria,
preventive service Task Force. Guide to clinical preventive services: report of
the us Prevelltive Evaluation for dysmorphic RBC or irritative voiding
4. primary renaI disease symptoms, chemicaI
& Wilkins' 1'096
Services Task Force. 2nd ed Baltimore: Williams cet[ casts, elevated
serum creatinine) exposu re)
5.CanadianTaskForceonthcPeriodicHealthEramination.c.anadianguidetoclinicalpreventive
health care. Ottawa: Canada Communication
Group' 1994:826-36'
** lfCT urogram is
6.Messing,EMetal.Homescreeningforhematuria:resultsofamulti-clinicstudy.JUrol,l992;
contra-indicated,
148:289-97.
screening by the detection of occult consider MR
7. Britton Jp et al. A community study of bladder cancer Urotogical evaluation*
Urol 1992; 148:788-90' urogfam, or
urinary bleeding. J
- Upper urinary tract
outcome in men underqoing hematuria home retrograde
8. Messing EM et al comparison of bladder cancer imaging by uttrasound pyetogram in
screeningverSusthosewlthstandardclinicalpresentations.Urologylgg5;45..387-97. kidney/btadder, KUB combination with
x-ray, CT urogram *+ non-contrast CT KUB
- Cystoscopy OT US
Foltow up as indicated
by diagnosis. Fottow persistent
Re-eva[uate for MH Fottow up with at AMH with annuaI
after resolution of least one uFEME UFEME. Refer for
identified condition yearly for at least two nephrotogic
years evatuation if
indicated. Repeat
urotogicaI evatuaiion
Discharge from fottow up
within 3 to 5 years if
c[inicalty indicated
especialty in high-risk
individuats
Physical examination should include ihe assessment for pallor, blood pressure measurement, an Contamination with vaginal secretions and vaginal skin is a very common occurrence, particularly in
abdominal examination and a per rectal examination if prostate enlargement is suspected. ln women, female, elderly patrents. This is especially common if the patient is heavy built and has a very deep
especially where the history is ambiguous, per vaginal examination should be performed to exclude introitus. The usual mid-stream urine is inadequate in reducing this contaminatron. We recommend that
gynaecological abnormalities. A urine culture is useful if there is suspicion of a urinary tract infection. a clean catch, mid- stream urine be collected after vaginal cleansing with wet cotton, and with the labia
Oiher investiqations include urine phase contrast microscopy, protein creatinine ratio, renal function minora parted, as seen in the diagram below. When this repeat specimen shows persistent WBC5 with
test (potassium. urea and creatlnine levels) and a full blood count. minimal epithelial cel!s. one should be obliged to investigate the patient.
appohtment to see a nephrologist. Simiiarly. if patients have symptoms and signs suggestive 01
.&ir
malignancy such as anaemia, loss of weight, loss of appetite and abdominal mass should be given an
and
tj,'f
early appointment to see an urologist. These patients would be counselled for possible diagnoses '\'*ri
pr"-urpt"d on possible investigations and management by the specialist. Also, patients' expectations
and anxiety would be managed accordingly.
Last, but not least, patients would also be advised that they can return to constrlt their Family
Physicians to clarify any concerns that they might have even after they have consulted the specialists.
Figurel. Sitling position for clean catch Figure 2 Parting the labia, and cleaning the meatus with wet
midstream urine cotton. The mid-stream urine sample is collected withoul
letting the labia re-appose.
,2 AN APPROACH TO COMMON UROLOGICAL DISORDERs I AN APPROACH TO ASYMPTOMATIC MICRO9COPIC HAGMATURIA (AMH) AN APPROACH IO ASYMPTOMATIC PYUEIA IANAPPROACHTOCOMMONUROLOGICALDISORDERS 33
of these wBCs Pyuria Once physiological and in{ective causes are excluded, other significant pathologies may also cause
when the diagnosis pyuria rs established, it is important to evaluate the source
tn an asymptomatic patient, the diagnosis o{ asymptomatic pyuria. lmaging modalities such as intravenous urogram (lVU) or CT intravenous urogram
can exist with-or without the presence of bacteriuria.
the various conditions that can can be done to exclude upper tract obstruction, malignancies or calculus disease. Cystoscopy and urine
a-rimple lo*", urinary tract iniection is very unlikely. Table 1. shows
cylology will also be required to exclude bladder ClS.
cause the Presence of PYuria.
REFEREI{CES
Table 1. The causes of asymptomatic pyuria
1. Richard Colgan et al. American Family Physrcian, September 15, 2006,Volume 74, Number 6,
Asymptomatic Bacteriuria in Adults
Nidus of infection
2. Ouslander JG et al. J Am Geriatr soc. 1996 Apr;44(4):420-3. Pyuria among chronically incontinent
lndwetting but otherwise asymptomatic nursing home residents.
cathete r 3. van Vollenhoven P et al. Urol Res. 1996;24(7):1 07-1 1. Polymerase chain reaction ln the diagnosis
of urinary tract tuberculosis.
PyuriaisexpectedinpatientsonlongtermindwellingcatheterandonpatientsWhoperformcle-an ^ I {
not imply infection ln fact,
internrittent self cathererization (Clse) (1). This is physiological and does lDC, CISC, partially Exclude contamination with Physical examination and
these cases, treatment is not routinely indicated in asymptomatic treated UTI clean catch mid slream urine
even when bacteria are identi{ied in PVRIJ assessment
resistancc to anti-microbial
individuals. Antibiotic therapy is more Iikely to promote baclerial
women or those planned for
treatment. However, active treatment is recotnnrended in pregnant
invasive urological Procedures.
m
The presence of mild pyuria in elderly females can be
physiological, as this is likely related to atrophic ,
females with underlying
urqi;ho in u port ,"nop.ural state iz). ln a study of nursing home resident Presence of cystocele or
a clean catch mid-stream urine sample showed the presence of asympLolrlatic
urinary inconiinence, urethral diverticulum
pyu,ialn+sv"oftheseindividualsWithoutclinicalevidenceclfalowerUrinarytractinfection.
Duringevaluation,adetaiIedphysicalexaminationistargetedtoidentifvanatomicaldisorderssuch
as cysioceles and urethral diverticuli in females. This is usually
evident on per-vaginal examination'
tn males, a prostate infection may yield tenderness on digital
rectal examination Post-void residual
bladder scan. An in-out catheterisation
urine volume (PVRU) can ue measurect by ultrasound or by a
are not available'
procedure can be done to quantify PVRU when ultrasound scans Teach patient to reduce
cystocele post void.
Thepresenceof'sterile'pyuriaoccurswhentheoffensivepathogencannotbeidentifiedontheusual lmaging / refer urology
culturemedium.TheCommonestcauseo{sterilepyuriaisthatoftuberculosis(TB)oftheurinary
rract. This can be asymptomatic if the kidneys are ihe ottly
urinary organ involved When tle bladder
is involved, the patient will usually have severe lower urinary tract symptoms. The investiqation of
void morning specimens for AFB smear and mycobacterium culture'
fhoice would be collection of firsi
polymerase chain reaction (PCR) is a
l-he latter generally takes 6 weeks to yield any results. The
whereby the presence of an
technrqueihat can be used to amplify a ,p".ifi. DNa gunomic sequence,
small number of bacteria can be detected. The high sensltivity of PCR is particularly useful in
extremlly
paucibacillary situations such as urinary TB (3)'
AN APPROACH TO ASYMPTOMATIC PYURIA AN APPROACH TO ASYMPTOMATIC PYURIA I AN APPROACH TO COMMON UROLOGICAL DISORDTRS 35
,i :c luleenolcrrTocoMMoNURoLoGlcALDlsoRDERsl
AI'l APPR0ACH T0 ASYMPT0MATIC PYURIA AND liro[)lerns with treating asymptomatic pyuria include anti-mrcrobial resistance, exposing patients to
potential side ef{ects of antibiotics as well as the cost of treatment (3).
BAGTEBIURIA: A FAMIIY PHYSICIAN'S PERSPEGIIUE
The decision {or a referral to the urologist often hinges on factors such as the presence of urinary
Dr Koong Ying Leng Agnes symptoms, significant risk factors for urological malignancies such as smoking, as well as patients desire
Director & Family Physician, Consultant, to undertake {urther investigations. Patients may also be empowered with the knowledge of symptom
SingHealth Polyclinics-Mari ne P arade recognition requiring them to seek consultation when required.
Asymptomatic pyuria is commonly encountered in the primary care setting as urine analysis is used
REFERENCES
to screen for micro-vascular complications of common chronic conditions such as diabetes and
hypertension. Therefore, the diagnosis o{ pyuria is usually incidental. 1. Zhanel GG, Nicolle LE, Harding GM. Prevalence of asymptomatic bacteriuria and associatecl host
factors in women with diabetes mellitus. Manitoba Diabetic Urinary lnfection Study Group. Clin
Pyuria, in the absence of symptoms. is often a result of contamination in the urine collection process. lnfect Drs 1995;21 :31 6-22.
As mentioned an this chapter, it is commonly seen in the elderly females. Asymptomatic pyuria is also 2. Renko M. Tapanainen P Tossavainen P, Pokka T, Uhari l\4. Meta-analysis of the srgniflcance of
more prevalent in the diabetics (1,2). asymptomatic bacteriuria in diabeles. Diabetes Care 34:230-233,2O1 1
3. Nicolle LE, Bradley s. colgan R, Rice JC, Schaeffer A, Hooton TM. lnfectious Diseases Society of
When asymptomatic pyu?ia is associated with epithelial cell contamination, a repeat sample should America Guidelines for the dragnosis and treatment of asymptomatic bacteriuria in adults. Clin
be obtained. However, obtaining a mid stream sample can be challenging for many of our patients ln[ect Dis 2OO5:4O.643-54
in the polyclinic setting. Patients may have difficulty voiding adequate urtne volumes during at
4. Harding GKM, Zhanel GG, Nicolle LE, Cheang M. Antimicrobial treatment in dlabetic women with
the laboratory as they may have fasting requirements prior to blood tests. Other dif{iculties faced
asymptomatic bacteriuria. Manitoba Diabetes Urinary Tract lnfection Study Group. N Engl J Med
include patients with incontinence, or those on fluid restriction for medical indications. lt is also time
2002: 347:1 57 6-83
intensive {or the laboratory stafl to give detailed instructions on the appropriate way to collect mid-
stream urine, in the face of a high patrent load.
We do not routinely perform urine cultures on these specimens. as the result often does not affect
management of the patient. However, in the context of literature review on this topic, most studies
involve patients with asymptomatic bacteriuria, whrch ts defined as
. 2 consecutive voided urine specimens with rsolatron of the same bacterial strain rn quantitative
counts > 105cfu/ml.
. 'l
A single, clean-catch voided urine specimen with bacterial species isolated in a quantitative
count > 1Oscfu/ml in men.
. A singe catheterized urine specimen with 1 bacterial specres isolated in a quantitative count >
105cfu/ml in women or men (3).
Physicians should evaluate for underlying causes of asymptomatic pyuria through evaluation o{
symptoms suggestive of urinary tract infection such as dysuria, frequency, haematttria, lower
abdominal pain and fever. lt is important to also illicit symptoms suggestive of lower urinary tract
obstruction as well as renal calculi disease.
The lnfectious Diseases Society of America Guidelines recommends that routine treatment of patients
with asymptomatic bacteriuria is not indicated, unless they are pregnant, or undergoing urological
procedures such as transurethral resection of prostate or undergoing procedures where mucosal
bleeding in the urological system is anticipated (3).
There have been cross sectional studies mentioned in a meta-analysis o{ the significance of
asymptomatic bacteriuria in diabetics, showing an increased association with the subsequent
development of symptomatic urinary tract infection. There appeared 1o be no significant differences
in creatinine level and glomerular filtration rate in diabetics with or without asymptomatic
bacteriu(a [3] However, in a randomized, controlled double blind trial amongst diabetic women with
asymptomatic bacteriuria, with or without anti-microbial treatment, patients who did not received
anti-microbial therapy did not have an increased incidence of urinary tract infection compared to
the group who received anti-microbial therapy. Neither was there a significant difference in renal
complications such as pyelonephritis or increased hospitalization days (4).
wnatri iHr inir,ro iN ilofi"il cartlcrn lNclDENcE? outcomes. Additionally, the study was thoughl to be more of a meta-analysis rather than a randomised
trial because of the varied screening protocols. However. the relative risk reduction in development of
prostate cancer is the third ntost common cancer in singaporean men. The tncidence is rising and
prostate cancer metastasis and cancer-specific mortality was consistent on extended follow-up and was
moremenarebeingdiagnosedatayoungerage.lnthetimeperiodfrom200gto20ll,theage- noted to be greatest in men between the age group of 55 and 69 years.
mortality rate was 54
standardised incidence rite was Ze.g p", tOO,OOO and the age-standardised
per 1 00,000. WHO WOULD BENEFIT FROM PSA TESTING?
(incidence) has increased from 94 cases in The main contemporary indications for PSA test rnclude
The number o1 newly diagnosed prostate cancer cases
the period 1g6a-1g72 toit88.ur., in the period 2003-2007.
The age-standardised incidence 1. follow-up after primary definitive treatment (surgery or radiation) for early,
't
rates have increased from 4.0 to 24.'l per 00,000
per year rn males during the same pericds The locally advanced and metastatic prostate cancer,
increased from 1 3 per 1 00'000 2.
age-standardised mortality rates for prostate cancer in males have prognostication of men diagnosed with prostate cancer,
peryearto+.7perto0,060pury"ui{ro*theperiod 1968-1972rotheperiod2003-2007witha 3. screening of high risk asymptomatic men,
decrease in the most recent period' 4. screening of men with lower urinary tract symptoms.
5. opportunistic screenrng of asymptomatic men between 55 to 69 years with
Comparatively,theproportionofmetastaticprostatecancerhasdeclinedoverthelasttwodecades
patients are diagnosed by transrectal ultrasound guided at least 1 0- l 5 years' life expectancy.
as a result of early detection with PSA. More
prostateneedlebiopsyaranearlierstage,Fewerpatientsarediagnosedbytransurethralresectionof
HiEh risk individuals include men with positive family history of prostate cancer and African-Americans.
prostate and bone biopsy.
WhIATDoTFIEPRoSTATEcANcERscREENINGTRIALSTELLUS? The American Urological Association 2013 guidelines do not recommend routine PSA screening of
any asymptomatic men below age 40 years, asymptomatic men rrJiih average risk between 40 and 54
Thereare2majorrandomisedprostatecancerscreeningtrialsWithinterimsurvivaloutcomes.The
years or above 70 years with less than 1 0-1 5 years' life expectancy. High risk men between 40-54 years
PLco(Prostate,Lung,Co|orectalandovariancancer)triallookedat76685men,aged55_74
years,rvhowereenrolledatl0sLreeninqCentersinUsAbetweenNovemberl993and]Uly2001 and men above 70 years with long life expectancy can be considered for PSA test. Between age 55
digital rectal examination) and and 69 years, counselling of risks of screening and overtreatment and shared decision-making for men
and randomly assigned to the interventi6n (psA testing and annual
considering PSA testing should be performed. Specifically, the benefit of preventing 1 mortality in 1 000
controlarms.afterl3yearsoffollow-up,theCumulativemortalityratesfromprostateCancerin
the intervention and control arms were 3.7 and 3.4 deaths
per 1 0 000 person-years, respectively, screened men over a decade needs to be werghed against the risks of over screening and overtreatment
resultinginanon.statisticallysignificantdifferencebetweenthetwoarms(RR=1.o9,95yoCl=0.87
cancer) trial looked at
to 1.36). The ERSPC (European"Randomized study of Screening for Prostate SUGGESTED ALGORITHM TOWARDS PsA TESTING
l82,l60menbetweentheagesof50andT4yearsenrolledineightEuropeancountriesbetween Patients with life expectan(y of less than 10 years
group, the relative reduction
19g5 and 2003. After a medln follow-up of 1 1 years in the core age
in the risk o{ death {rom prostate cancer in the screening
group was 21Yo (rat9 ratio' 0 79; 95% i. Asymptomatrc patient -> no role for PSA testrng
for noncompliance'
confidence interval [cl], 0.68 to 0.91; P = 0.001), and2gok after adjustment ii. Pre;ei rce o{ lower urinary tract symptoms (LUTS) or abnormal DRE -> consider PSA testing and
relative risk reduciion in the development of prostate cancer metastasis was 3070 (hazard ralio
The urological evaluation
[HR]: 0.70; 95% conficlence interval [ct]'
0 60-0 82; p = 0 001) To prevent one death from prostate
cancer at 1 i years of follow-up, 1 055 men would need to be invited
for screening and 37 cancers
would need to be detected. Tire resulting numbers needed to invite
for screening to avoid I case of
metastaticcliseasewas328,andlhenumbersneededtodiagnosewasl2.
ANAPPROACHTOPROSTATESPECITICANTIGEN(PSA)ANDPROSTATEONCERSCREENING IANAPPROACTITOCOMMONUROLOGICALDISORDERS 39
j3s I AN APPROACH TO PROSTATE SPECITIC ANTIGEN (PsA) AND PnOSTATE CANCER SCREENING
AN APPROACfl TO CONIMON UROLOGICAL DlsoRDERS
PATIENTS WITH LIFE EXPECTANCY OF MORE THAN 1O YEARS PR0STATE CAilCER SGBEENING: THE FAMILY PllYSlGlAN,S
i. Asymptomatic patient - pros and cons of PSA testing (screening) needs to be discussed PERSPEGTIUE
ii. Presence of LUTS or abnormai DRE -> recommend PSA testing and urological evaluation
Dr Gilbert Tan
Director & Consultant Family Physician, SingHealth Polyclinics-Geylang
REFERENCES
1. National Registry of Diseases Office. Singapore Cancer Registry lnterim Annual Registry The family physician (FP) is often the first point of contact for patients requestinq for prostate cancer
Report:Trends in Cancer lnctdence in Singapore 2007-2011. Webpage http://www.nrdo.gov.sg screening. The approach of the FP should begin with exploring the ideas, concerns and expectations
accessed on 6 June 20'13. (lCE) of the patient with regards to prostate cancer screening. Patients often see all screening tests for
2. Andriole GL et al. Prostate Cancer Screeninq in the Randomized Prostate, Lung, Colorectal, and cancers as equally useful and effective. They may also have misconceptions about screening tests and
'13 Years of Follow-up. J Natl Cancer lnst
Ovarian Cancer Screening Trial: Mortality Results after their applicability. By obtaining the ICE o{ the patient, the doctor can provide patient-specific education
2012:104.125-132. and advice for or against prostate cancer screening. The patients age and health status should also be
3. SchrOder FH et aI.ERSPC Prostate-Cancer Mortality at 1 1 Years of Follow-up. N Engl J Med taken in consideration.
20'12; 366:981-90.
4. Schroder FH et al. lqreening for Prostate Cancer Decreases the Risk of Developing Metastatic The next task for the FP would be to assess if the patient is at high or low risk for prostate cancer. High
Disease: Findinqs from the European Randomized Study of Screening for Prostate Cancer risk includes patients with a strong positive family history of prostate cancer (diagnosed before 65 years
(ERSPC). Eur Urol 201 2; 62: 7 45-7 52. of age - father and/or brothe(s)). The FP should also check for presence of any siqnificant symptoms
such as lower urinary tract symptoms and bladder outlet obstruction. There is a role for screening
5. American Urological Association guidelines on early detection of prostate cdncer. Webpage
in those who are high risk or symptomatic. ln other clinical srtuations, the FP should assess clinical
http://www.auanet.orgleducation/guidefineyprostate-cancer-detection.cfm accessed on
rndicatlons for screening and ensure that the patient makes an informed-choice about the benefits
6 June 2013
versus harm of screeninE.
Screening at the primary care setting includes both digital rectal examination (DRE) and Prostate Specific
Antigen (PSA) testing. ln low risk, asymptomatic individuals, a normal DRE and PSA levels less than 4 ng/ml
is assuring. But rajsed PSA levels and/or abnormal DRE would mean a referral to the urologist for {urther
workup including possible invasive prostate biopsy. The abnormal screerring outcon.re also crcates a sense
of anxiety in patients that must also be addressed bV the FP
40 AN APPRoACH To coMMoN UnoToGIcAT DISoRDERS I AN APPROACH TO PROSTATI SPCOTIC ANIIGEN (PsA) ANO PROSTATE CANCTR SCREENING AN APPNOACH TO PROSTATE SPECIFIC ANTIGEN (PSA) AND PROSTATE CANCER SCiEENING I AN APPROACH TO COMMON UROLO6ICAL DISORDERS 41
I A]ll APPROAGH TO EREGTILE DYSFUNCTION HOW SHOULD I EVALUATE THE PATIENT IN THE CLINIC?
A full medical history including medications, previous admissions and surgery should be taken. The
Dr Chong Tsung Wen severity of comorbidities may require moderation of sexual activity. While medications may be the
underlying cause of ED, they commonly also aggravate the condition. Lifestyle factors and possible
substance abuse such as alcoholism and smoking should also be noted.
HOW DO WE DEFINE ERECTILE DYSFUNCTION (ED)?
A sexual history should include the onset and duration of the problem, presence of nocturnal or early
Any persons who subjectively complains of absent or poor quality of erectlon despite
morning tumescence and a sexual assessment questionnaire such as the llEF score. Such questionnaire
sexual arousal is said to be suffering from erectile dysfunction. There is increasing evidence that
ED
forms the basis for diaqnosis and determines the severity. Conditions such as premature ejaculation,
can be an early manifestation of coronary artery and peripheral rrascltlar disease. Tl.rus ED should not
infertility and sexual disorders should not be confused with ED.
only be regarded as a QOL issue but also as a potential warninq sign
of cardiovascular dlsease.
Examination of the genitalia should include observation of the testicles, penile size and any
abnormalities such as penile nodules or curvatures. Older men with urinary symptoms may require a
WHAT IS THE INCIDENCE OF ED? digital rectal examination of the prostate for malignant changes. Blood pressure and peripheral pulses
The incidence of ED ls high but the exact incidence may not be fully known as many sufferers do not examination are mandatory to assess for undiaglnosed or poorly controlled hypertension.
seek advice. Previously seen as an inevitable consequence of aging; recent advances in treatment
highlighted in the media has led to qreater public awareness and increasing demand fr-'i medical WHAT INVESTIGATIONS SHOULD I DO?
treatment.
The only screening test required is a urine dipstick for haematuria, glycosuria or proteinuria which, if
present, will require fr.rrther work-up. Other investigations shoutd be directed by the history artd physical
A lvell-conducted population study on agin9, the Massachuseits Male Aging study, showed the
prevalence of ED to be 50% among men above 50 years. This incidence increases 10% for every
examination. Glvcosuria should be followed up with fasting glucose and HbA'lc levels to diagnose
diaberes. Lipid proflles shoutd be included in the fasting specimen. Presence of significant lower urinary
decade of life thereafter. ln that study, most male suffer from mild to lnoderate ED wirh only about
1 O% has severe ED. Singapore is likely to have similar rates.
tract symptoms or an abnormal rectal exam of the prostate should be followed by a discussion with the
patienr on PSA (prostate specific antigen) testing. Loss of libido, lethargy and findings of atrophic testis
may call for deterrnination of hormonal levels (morning testosterone (total and free) levels).
WHAT IS THE ETIOLOGY AND HOW DO WE CLASSIFY THEM?
Traditionally, the etiotogy of ED is classified as Organic or Psychogenic The Third Princeton Consensus orr sexual function and cardiovascular health has identified low risk
paiients as those without any significant cardiac history, symptoms or risk factors (< 3 risk factors).
Organic causes: These patients do not require further cardiac evaluation. lntermediate risk groups with significant risk
1 Artcriogenic;arterio-occlusivedisease,pelvicsurgery factors (= or > than 3) or uncertain cardiac conditions should undergo stress testing to clarify therr
2. Venous leakage cardiac status. High risk patients with su{ficiently severe or unstable cardiat: conditlons should be
3. Neurogenic; peripheral neuropathy from diabetes, spinal trauma referred lo the Cardioloqist.
4. tndocrine;testicularatrophy,orchidectomy, hypopituitarism
WHAT ARE THE KEYS TO SUCCESSFUL TREATMENT OF ED?
5. Penile abnormality; hypospadius, chordee, Peyronie's disease
6. Drugs;
A stepwise approach based on severity has been proposed but it has been more popular in clinical
practice to begin with the least invasive treatment therapy which is oral medication together with
. hypotensiveaqents:beta-blockers,thiazides
lifestyle chanqes and risk factor modification.
. anticholinergics:tricyclicantidepressants
. hyperprolactinaemiamedications:domperidone ,!. ORAL MEDICATION
" anti-androgens:cyproteroneacetate,cimetidine,oestrogens To date there are three available on-demand oral PDE5 inhibitors for treatment of ED; Sildenafil (Viagra),
. others: clofibrate. MAOIs Tadalafil (Cialis) and Vardenafil (Levitra). There is no data directly aoF,]paring the efficacy of the 3
. drugs of abuse: smoking, alcohol, heroin and methadone drugs. Ultimately the choice of drug depends on frequency of sexual intercourse and patient's personal
experience with each. Sildenafil and Vardenafil have efficacy of up to 12 hours, wrth Tadalafil beinq the
longer acting drug up to 36 hours. once-a-day oral dosing of Tadalafil (5mg) is now available. This form
Psychogenic cause: of therapy is particularly suitable for couples who prefer more spontaneous or more frequent sexual
1. Depression intercourse, with the advantage that dosing and sexually activity need no longer be temporally linked.
2. Stress Adverse reactions are usually a class effect related to PDE5 inhibition with some minor differences
(check with individual drug information sheet). The two main reasons for failure to respond to PDE5
3. Performance anxiety
inhibitors are either incorrect dosing or inappropriate drug (related to duration of action). ln addltion,
4. Traumaticexperiences
PDE5 inhibitors rely on release of rritric oxide from parasympathetic nerve endings following sexual
stimulation, without which the drugs will not work. Clinical trials have not demonstrated any effect on
Such distinction is neither cleat-cut nor always exclusive in clinical practice as ED of any organic cause
cardiac function or increase in myocardial infarction rates in patients receiving PDE5 inhibitors. However,
may over time develop a psychogenic component, such as, performance anxiety and depression.
concomitant use of Nitrates is an absolute contratndication.
Conversely, psychogenic causes may have an organic basis in terms of neurotransmitter imbalance
I
ANAPPROACHTOERECTILEDYSFUNCNON
44 AN APPRoACH TO CoMMON UBOIOT]ICAT DISORDERS I AN APPROACH TO ERECTILE DYSFUNCTION IANAPPROACHTOCOMMONUROLOGICALDISORDERS 45
excessive pubic 10
DO use a water-soluble lubricant to obtain an air-tight seal and if necessary, shave any AN APPROAGH TO PREMAIURE EIAGULATION
hair. lntermittent pumping may produce a more engorged penis with
more satisfactory rigidity.
Dr Lee Lui Shiong
DO consider using tension band with a ventral notch if patient complains
of inability to ejaculate' Do NoT Consultant, Depafiment of Urology, Singapore General Hospital
penis'
apply the tension band beyorrd 30 mins to avoid ischemic in1ury to the
HOW DO WE DEFINE PREMATURE EJACULATION (PE)?
Do NoT use in patient with bleeding tendency or on anticoagulation therapy' The current definition of primary premature ejaculation (PE) is based on that proposed by the
lnternational Society for Sexual Medicine in 2008(1) - "... a male sexual dysfunctron characterised by
lnsummarysafe&effectivetreatmentoptionsforEDareavailableprovidedpropermeasuresare ejaculalion which always or nearly occurs prior to or within about one minute of vaginal penetration;
cardiovascular risk Risk
taken to a;hieve the optimal results. ED rtay be associated with an increased and inability to delay ejaculation on all or nearly all vagrnal penetrations; and negative personal
of patients with ED for further cardiac evaluation is important ln addition, although PDE5
stratification consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy."
physical stress ensuing vigorous
inhibitors themselves do not affect cardiac function, the unaccustomed
patients to a specialist early for
sexual activity may lead to cardiac related issues. lf necessary, refer these Therefore, men diagnosed with PE as a sexual disorder have short intravaginal elaculation latency time
a thorough assessment & advice prior to starting these
patients on ED treatment'
(lELT. less than one minute) with poor eyaculatory control. This has been shown to have negative impact on
both the patient and tlreir partners (2). Single men with PE are also affected.
Where previous de{initions of PE have not taken into account the impact of IELT, patients have
historically been erroneously diagnosed with PE
AN APPR0AGII T0 EREGTILE DVSFUNSTI0N: A FAMILY
WHAT IS THE PREVALENCE OF PREMATURE EJACULATION?
PHYSIGIAN'S PERSPE TNE
The prevalence of premature e.iaculation (PE) has been quoted as between 2o-30% (3,4). However, one should
distinguish 'PE' as a symptom or complaint from the patient, versus a diagnosis ol PE as a sexual disorder.
Dr Peter Moey Kirm Seng
Cmii oirecior SingHbalth Potyclinics, Pasir Ris Polyclinic
The presence of early ejaculation does not always represent premature ejaculation as a
patients presenting to Family Physician (FP) for Erectile Dysfunction (ED) frequently attribute it to sexual disorder.
anti-hypertensives such as
medications prur.iib"d for clrronic diseases such as hypertension. Some
establishing the temporal
beta-blockeri, do indeed predispose an individual to ED. ln this situation, It is now recognised that ejaculatory disorders in men repi'esent a spectrum, including lifelong PE,
sequence of events leading up to development of ED is imporlant. acquired PE, natural variable PE,and PE-like ejaculatory dysfunction(5).
patierlts occastonally stop chronic disease medications because of developmcnt of ED Clrronic HOW SHOULD I EVALUATE THE PATIENT lN THE CLlr\ilC?
disease control should take precedence over ED treatment, as
poor control o{ chronic conditions can
alcohol and poor control The patients clinical and medical history is crucial to diagnosis of PE. There should be specific fotus on
worsen ED besldes leading to other cardiovascular complications. smokitrg,
should be emphasised' the duration or symptoms, such as whether it is srtuational (specific partner or specific situation), length
of chrcnic conditions all contribute toward ED and appropriate intervention
of time from vaginal penetration to e.iaculation. degree of sexual stimulus and the impact of PE qn
patients and counselling offered quality of lite (QoL). lt is crucial to estabilsh the perceived amount of e.jaculatory control during cortus,
stress and depressiorr can cause ED and should also be explored in
professionals such as and the amount of distress and negative impact on the relationship resulting from a lack thereof. The
if indicated. lt may be helpful to involve family members and other healthcare presence of drug usage and concurrent erectile dysfunction (ED) should be established.
psychologists or psychiatrists
medical social *oik.rt, Family Service Centre personnel,
Physical eiiminatron should he aimed at identifying physical or structural abnormalities in the external
physical iitness for sexual activity should be assessed for patients who have been sexually/physically
taking, physical examinatlon and genitalia, such as Peyronie s disease, sexually transmitted diseases, phrmosis and other scrotal lesions.
inactlve prior to prescribing ED medications. After relevani history
Choice of medication and An examination of the neurological, vascular and endocrine may rqyeal other systemic disorders that
investigation, a irial of the appropriate PDE5 inhibitors may be prescribed. predisposes to male sexual dysfunction such as thyroid disorders and diabetes mellitus. There are no
patienieducation on pDE5 usage are important factors in the management of ED. Where an organic
pors are contra-indicated or ineffective, patients may then be referred routine laboratory investigations jndicated in the evaluation of PE, but are directed from abnormal
cause for ED is suspected or if
findings at clinical evaluation. A significant overlap in IELT has been observed between normal men
to the Urologist.
and those with PE, thouqh a median time of 5.4 minutes has been reported for normal populations
(6). Therefore, the use of IELT alone is not sufficient to diagnose PE. ln randomised controlled trials.
The FP may face ethical dilemmas when patients seek treatment
for sexual activities outside marriaqe'
discharge lris duties professionally, the female partner measures IELT with a stopwatch. The time period measured commences at vaginal
It would be appropriate for the FP to respect patients' choices and penetration and ends at the point of ejaculation. ln a situation where ejaculation occurs prior to
including ,uintuining patient confidentiality and dispensing advice on safe sexual practices.
penetration (ejaculatio ante portas), the IELT is defined as zero. ln practice, a stopwatch is not necessary
and where needed, patient estimates are usually sufficient.
l
Both genetic and epigenetic (8) factors may play a role in development of lifelong
PE. This is.based on THE ROLE OF THE FAMILY PHYSICIAN (FP)
oicuning in twins or in familial studies (9). There{ore lifelong PE is more likely an Patients with PE may find i1 dif{icult to come forth wilh their complaints. The detection of such
studiJs showinq PE
inherent disease. sexual disorders may need direct prompting by the physician especially if patients are hesitant. lt is
usually beneficial to have the patients sexual partner present during the consult, although it may be
on the other hand, acquired diseases, and situational or envircnnletlt:l factors 'l'lay cause acquired occasronally necessary to have complete privacy for the individual.
PE and other PE-like disorders.
Once identified, these patients will benefit from an initial assessment by the urologist. They may then
WHAT ARE THE KEYS TO SUCCESSFUL TREATMENT OF PE? subsequently be discharged to their FP {or continued care.
TREATING LIFELONG PE 1. McMahon, C.G.. et al., An evidence-based de{inition of lifelong premature eiaculation: report
of the lnternational Society for Sexual Medicine (ISSM) ad hoc committee for the definition of
lnprimaryPE,psychologicalcounsellingmayhavealimitedrole'Themainstayoftherapyrelieson
patients although drugs ate premature ejaculation. I Sex Med, 2008. 5(7): p. 1 590-606.
medical tierapy.'No wiJely accepted cure is currently available for these
useful to portpon" the ejaculatory response. The goal of therapy is to
prolong the ejaculatory time 2. Patrick, D.1., et al., ORIGINAL RESEARCH-EIACULATORY DISORDERS: Premature Ejaculation: An
Observaiional Study of Men and Their Partners.
and rncrease eiaculalory control
The journal of sexual medicine, 2005. 2(3): p. 358-367.
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (55RIS) 3. Laumann, E.O., et al., Sexual problems among women and men aged 40-80 y: prevalence and
setraline correlates identified in the Global Study of Sexual Attitudes and Behaviors. lnt J lmpot Res. 2005.
These drugs are first Iine treatment in PE, and include dapoxetine,paroxetine'
1 7 (1): p. 39-57 .
and fluoxettne.
4, Hartmut. P, et al., The Premature Ejaculation Prevalence and Attitudes (PEPA) Survey: Prevalence,
previously, these agents have been prescribed on a daily basis. and shown to prolong the IELT in Comorbidities, and Professional Help-Seeking. European urology,2006.51(3): p.816-824.
various studies. A meta-analysis suggests that paroxetine exerts the strongest
e{fect (10). 5. Waldingel M.D., Premature ejaculation. Drugs, 2007. 67(4): p. 547-568.
6. Giuliano. F., et al., Premature ejaculation: results from a five-country European observational study.
as an on-demand oral
More recently, dapoxetine (30mg and 60mg) has been shown to be effective Eur Urol, 2008. 53(5): p. 1048-57.
pE. trials demonstrate prolon-oation of IELT from 0.9 minutes at
treatment fo; Randomised clinical
(11) Similardosedependent
7. tv1D, W, Tlrc neurobiological approach to premature ejaculation. I Urol, 2002. 168: p.2359-2367.
baselineto1.8min(placebo),2.8rrrin(30mg)and3'3min(60mg) B. Waldinger, 1,4., et al., Familial o.currence of primary premature ejaculation. Psyclriatric Genetics,
placebo, 30mg
improvements in lELi was also observed in another clinical trial comparing between 1998.8(l): p.37.
and 60mg (12). The clinical e{{ectiveness was apparent on first dose'
9. iern, P, et al., Prerrature and Delayed Ejaculation: Genetic and Environmental Effects in a
one to three hours Population-Based Sample of Finnish Twins. The;ournal of sexual medicine, 2007. 4(6): p. 1139-
Dapoxetine was approvecl for usage in singapore from March 201',l, and is taken
1749.
prior to coitus.
'10. Waldinger, M., Towards evidence-based drug treatment research on premature ejaculation: a
(7.7-13.AVo), diarrhoea critical evaluation of methodology. lnternational journal of impotence research, 2003. 1 5(5): p.
Common side effects of dapoxetine include nausea (16.5-30.6%), dizziness
(3.9-1 1.3%) and headache (64-13.6Y"). These adverse effects lead to drug discontinuation
in '1 37o, 309-3 1 3.
3.9 and 8.2% of patients (placebo, 30mg , 50mg) in the trial
(12)' 1 1. Pryor, J.1., et al., Efficacy and tolerability of dapoxetine in treatment of premature ejaculation: an
integrated analysis of two double-blind, randomised controlled trials. The Lancet. 368(9539): p.
yawning, nausea
There are short and long term side effects related to ssRls. The former include fatique, 929-937.
and perspiration. These are short term and disappear within the first month of starting treatment. 12. Buvat, J., et al., Dapoxetine for the Treatment of Premature E.iaculation: Results from a
Randomized. Double-Blind, Placebo-Controlled Phase 3 Trial in 22 Countries. European Urology,
The long term side effeds include weight gain and development of diabetes mellitus. A rare side 2009. 55(4): p. 957-968.
with ,13.
effect oi Ssttts include a.bleeding diathesis (1 3), which may be more pronounced in combination Weinrieb, R.M., et al., Selective serotonin re-uptake inhibitors and the rask of bleeding. Expert Opin
non-steroidal anti-inflammatory agents. Drug Saf, ZOO5.4(21: p.337-44.
All patients should be advised against stopping ssRl therapy acutely as it may lead to SSRI
14. Black, K., et al., Selective serotonin reuptake inhibitor discontinuation syndrome: proposed
disLontinuation syndrome ( l4).
diagnostic criteria. J Psychiatry Neurosci, 2000. 25(3): p. 255-61.
prior
ln patients with underlying psychological disorders, a formal psychiatric assessment is indicated
to starting SSRls.
SECONDARY PE
The successful management of secondary PE relies on identification and treatment of its underlying
cause. For example, secondary PE may occur as a complication of erectile dysfunction (ED). ln this
particular situation, the male partner hastens to complete the act of coitus before detumescence
occurs.The appropriate clinical management involves treatment of ED
The stop-start technique is more popular among sex therapists because tt is easier for health
Primary PE professionals to explain and for patients to use (4-5). Couples can learn to incorporate 'stop-start'
Itifetong) technique into their sexual script. The stop - start approach involves an exercise in 'communication' and
comprises these five steps:
1. The couple will stop having penetrative sex for a while. This ban serves to decrease the man's
performance anxiety.
2. During a couples first lessons, the woman uses her hand to arouse the man and stops the motron
MedicaI therapy Treat predisposing when he signals her to.
(SSRls) co ndition 3. This happens three or four times on any one occasion before he eventually ejaculates.
4 The next step is the stimulation of the penis with the aid of lubrication. This step is thought to
be essential as the initial 'dry' stimulation of the penis does not adequately match the sensations
experienced by the man once vagirial penetration is reintroduced.
5. The couple then integrates this technrque into intercourse experiences with frequent'pauses'.
AN APPROAGIN TO PREMAIURE EJAGUI,ATION:
A PSYGTIIATRIST'S PERSPEGNUE It is always useful to go on practicing stop-start from time to time cven afler the man has overcome his
PE (3). The reason behind this recommendation is that certain situations can increase the likelihood of
Dr Ng Beng Yeong a relapse of PE, for exanrple, a period of time without any sexual activity, which can happen when the
Senlor C6nsultant, Department of Psychiatry, Singapore General Hospital wile becomes pregnant.
WT.IAT IS PE? Sexologists Masters and Johnson developed a variation of the start-stop technique, called the squeeze
ln DSM-5. premature ejaculation (PE) is a persistent or recurrent pattern o{ ejaculation occurring lechnique (2-4). With this technique, rather than merely stopping stimulation to the penis, the man3
partner is instructed 10 grasp the corona of his penis with her index and middle finger against her thumb,
during partnered sexual activity within approximately 1 minute following vaginal penetration and
before ihe individual wishes it (1). lt must have been present for at least 6 months and must be applying firm pressure for approximately 20 seconds. l-his will cause the man to lose his urge to ejaculate.
CauLiorr rreeds to be exercrsed as it can be painful if too much pressure is applied. For this reason some
experienced orr almost all or all (approximately 75% -- 100%) occasions of sexuai activity. Estimated
sex therapists lrave modified the technique that the man performs this manoeuvre himself. Locally, some
and measured intravaginal ejaculatory latencies (IELT) are hiqhly correlated as long as the ejaculatory
latency is of short duration; therefore, self-reported estimates o{ ejaculatory latency are sufficient
women may not cooperate with this treatment as they are reluctaiit to touch the mans penis (4).
for diagnostic purposes. with the new definition of premature (i.e., ejaculation occurring within
:
approxinrately 1 minute of vaginal penetration), only 1% 3% o{ men would be diagnosed with
Sorne men may object to the stop-start technique and squeeze technique as manual stimulation is
ihe disorder (1 not culturally acceptable to them. Fear and guilt that masturbation may have been 'weakening'seems
).
stronger in Asian cultures. Also. not all patients are able to identify the 'point of inevitability'; they may
DSM-5 also highlights the need to consider multiple contributing factors when evaluating a patienr have a short arousal phase and an almost non-existent plateau phase of their arousal cycle. Behavioural
with any sexual dys{unction. These factors include: 1) partner fac[ors (e.g., partners sexual problems, treatment might be much more successful in men with premature-like elaculatory dysfunction than in
partner,s health status); 2) relatronship factors (e.g., poor communication, dlscrepancies in desire men with lifelong or acquired premature ejaculation (2). ln premature-like ejaculatory dysfunction, men
for sexual activity); 3) individual vulnerability factors (e.9., poor body image, hrstory o{ sexual or complain of premature ejaculation, but the IELT is in the normal range or even has a long duration.
emotlonal abuse), psychiatric comorbidity (e.9., depression, anxiety), and stressors (e-9., job loss,
Sensate focus can also be useful. The couple is encouraged to spend time in mutual pleasuring involving
bereavement);4) cultural/religious factors (e.g. inhibitions related to prohibitions against sexual
attitudes toward sexuality); and 5) medical {actors relevant to prognosis, course, or nongenital massaqe and caressing (2). This reduces the genital focus of the ejaculatory control process,
treatment (1). and again conditions the man to higher levels of sensation and stimulation. Sensate focus requires a
cooperative partner and sufficient time to follow the programnre properly. lf the usual 'order' of sexual
50 AN APPROACH TO COMMON UROLOGICAL DIsORDERS I AN APPROACH TO COMMON PREMATURE EJACUUTION AN APPROACH TO COMMON PREMATURE EIACUTATION I AN APPROACH TO COMMON UROLOGICAL DISORDERS 51
events is such that the man ejaculates before his partner is stimulated, this process can be altered so
that attention is glven to the woman's satisfaction and possibly. orqasm, be{ore or after vaginal entry
11 AN APPROACH TO HAEMATOSPERMIA
occurs (3). The treatment of PE may change aspects of foreplay rather than ejaculatory control. Also,
Dr Henry Ho
some couples may forget the coniinuation of pleasuring which is possible after ejaculation.
Consultant, Deparlment of Urology, Singapore General Hospltal
A man may seek treatment for PE even if he has no partner. For such cases, it is important to provide
him with the relevant information and let him learn specific techniques such as stop-start while WHAT IS HAEMATOSPERMIA?
masturbating. lt is important to assist the man psychologically to develop his own sexual confidence, Haematospermia is defined as the presence of blood (with or without clots) in the ejaculate. There are
increase his repertoire of sexual skills and thus enabling him to look for a partner (4). many causes of haematospermia including infections, malignancy, and inflammatory causes as detailed
in Table 1.
COMPLICATIONS OF PE
Erectile dysfunction can be a distressing complication of premature ejaculation. Lack of confidence in
Table l. C.ruses 6[ Haemalospermia
one's own ability to avoid PE can lessen his desire for sexual contact and undermine his erection Tlris
can lead in some instances to the avoidance of sexual situations altogether. More intensive work will Aetiotogy Ctinicat Featu!'e
be required in the treatment of such complicated cases. Psychotherapy might be helpful for the man
BehavioraI lsotated episode triggered
who is prepared to examihe all aspects of a {ailed relationship, sexual and otherwise (5).
Excessive sex or masturbation by particu[ar behaviour
lnterrupted sex
REFERENCES
Pro[onged sex abstinence
1. Draqnostic and Statistical Manual of Mental Disorders, Fifth Edition. DSM-5lAmerican
Psychiatric Association. 201 3. lnfection lrritative genitourinary symptoms
2. Richard Balon et al. Delayed and premature eyaculation. ln: Clinical Manual of Sexual Disorders. Gram-negative uropathogens AbnormaI urinatysis / cutture
Edited American Psychialric Publishing, 2009, pp. 273-304. Sexuat[y transmitted disease
3. Vicki Ford. Overcoming sexual problems. London: Robinson. 2005. \ Mycobacterium tubercutosis
Schistosomiasis
4. Ng Beng Yeong. Cominq of age: an integrated approach to premature e.jaculation. Singapore
Ec hi noccrccus
Family Physicians 2005, Vol 31. No 2 (Srrppl), AprilJuneZAO5:42-45
5. I'Jg Beng Yeong. Treatmentof difficult cases and advanced counselling techniques. ln: lnftammatory lrritative genitourinary symptoms
Premature ejaculation how to investigate and treat. Edited by Peter Lim Huat Chye. Society for
- Prostati tis AbnormaI physicaI findings
Mens Health Srngapore. 20'1 1, pp.45-50. Epididymo-orchitis AbnormaI urinaLysis / culture
52 AN APPROACH TO COMMON UROLOGICAL DISORDIRS I AN APPROACH TO COMMON PREMATURE EJACULAIION ANAPPROACHTOHAEMATOSPERMIA IANAPPROACHTOCOMMONUROTOGICALDISORDERS 53
ALGORITI-IM FOR AN APPROACH TO HAEMATOSPERMIA
HOW DO I EVALUATE THE PATIEI{T?
history, demographic, risk factors
The evaluation of haematospermia should be directed by the clinical
and urinalysis.
History
AcompleteclinicalhistoryisrequiredtoexclUdepseudo.haematospermiawhichincludesnon- Exctude Pseudohaem atospermia
partner source The duration
reproductive tract source e.g haematuria, external genitalia iniury or LUTS
symptoms and genital
and frequency of haematospermia along with associated lower urinary GeniiaI symptoms Associated LUTS
symptoms like pain ciuring ejaculation or sexual intercourse are important' Sexua[ /systemic disease
as causes of haematospermia
Recent instrumentation like prostate biopsies is Llsually clinically apparent
Haematospermia is the presence of blood in the ejaculate. The incidence is estimated at 1 in 5,000
The abdominal exam should assess for signs of blunt trauma and lymphadenopathy.
new patients referred to urology clinics (1). The true incidence in the community is probably hlgher
patient. lt may also be The penis should be inspected to rule out obvious lacerations, trauma or lesions that may contribute [o
as most ejaculations are intravaginal, and bleeding not apparent to the
the bleeding. The scrotum, epididymis and testes should be examined for masses, and the vas deferens
underestimated as most cases are transient, and may not prompt medical attention. In men less than
palpated along their course to check for irregularity or nodularity, which may suggesr tuberculosis.
40 years of age, haematospermia is most likely benign.
The digital rectal exam should note the prostate size, tenderness, fluctuation, symnretry, firmness and
Some men will not look at their semen post ejaculation. and as such. haematospermia may
be
nodularity. An attempt should be made to palpate the semrnal vesicles (normally, the seminal vesicles are
noticed by their partners or picked up after seeing blood-stained linen
non-palpable). The presence of a midline cyst may indicate the presence of ejaculatory duct obstruction.
Forthe patient, this finffng of bleeding can be terrifying. The usual first point of contact is a {amiliar
General Practitioner and most cases can be effectively rranaged as such
TREATM ENIT FOR I-IAEMATOSPERMIA
Antibiotrc therapy is incjicated in cases where an infectious etiology is suspected. l-he duration of therapy
The causes of haematospermia broadly include: is usuall;r 2 weeks, and choice of therapy is usually a fluoroquinolone that penetrates the prostate well.
1. Prostate: Recent TRUS-guided prostate biopsy, prostatitis, prostatic cysts, prostate cancel Alternatively, a combination of trimethoprim/sulfamethoxazole and doxycyciine will adequately cover
prostatic telangectaisa/varices, recent treatment for prostate diseases ( TURB brachytherapy) enterobacteriae and chlamydial infections. The r-rse of NSAIDs can reduce concomitant inflammation.
Bleeding diatlresis or other systemic disorders should be managed accordingly if already previously
2. Urethra: Urethritis, cysts, polyps, condylomata and strictures
known.
3. Seminal Vesicles: Seminal vesicle cysts. amyloidosis
4. Infections: TB, HIV HSV, Chlamydia trachomatis, schistosomrasis When to re{er to an uroloqist
5. Trauma: haemorrhoidal injections, urethral self-instrun-rentation, testicular or perianal blunt trauma.
i. Persistent haematospermia ( > 2 montlrs) or recurrent haematospermia
6. Systemrc Disorders: Hype(ension, chronic liver disease, amyloidosis, lymphoma, bleeding diatheses.
ii. All patients with concomitrnl haematuria on UFEME
A practical approach for the GP would be thus iii. ln men 40 years or oldet especrally with associated symptoms of fever, chills, weight loss or bone
1. History, pain or elevated PSA.
2. PhysicalExamination
3. Investigations, especially for red flag conditions that require relerral IDEAS, CONCERNS AND EXPECTATIONS
4. Addressing the ldeas, Expectations and Concerns of the patient. It should be noted that addressing the patients ideas, concerns and expectations should be applied
throughout the consultation process and not just at one instance.
HISTORY ln sexually active patients at risk of STl, it is an opportune moment to assess sexual practices and
advocate safe sex/ risk reduction strategies.
3 key factors help guide further management: Age of the patient, duration of the symptoms and
presence of associated symptoms or risk factors.
Well-intormed patients are also more Iikely to seek background information (internet) prior to clinical
i. ln men younger than 40 years, history should be {ocused on behaviour related haematospermia consultation. They may harbour their own beliefs about prolonged sexual abstinence, excessive
(sexually
such as exceisive masturbation, vigorous intercourse, and infectious etiologies ,nasturbation or rigorous sexual intercourse. An open mind and a non-judgemental consultation will work
transmitted infections, STls) best in such situations to address their underlying concerns.
ln men above 40 years of age, anaiomic abnormalities and abnormal growths should be
considered. Most patients would benefit from reassurance that haematospermia is usually selfJimiting
ii. persistent or recurring haematospermia, such as 10 episodes or more persisting for 1 2 weeks and would resolve spontaneously in around a few weeks or approxrmately 1 0 e.iaculates. They also need
require further evaluation. to be advised that haematospermia may also change in colour from red to rust brown gradually.
iii. The presence of lower urinary tract symptoms such dysuria may suggest urethritis. cystitis or
prostatitis. Pain with ejaculation may include prostatitis or an obstruction of the ejaculatory ducts. olcier patients may be worried about cancer, or conversely, choose to ignore their symptoms
Voiding symptoms may hint towards concomitant bladder or bladder oullet conditions or completely. The caveat is "to comfort always" and it is help{ul to encourage them to come forth
anatomic abnormalities. Although rare in this setting, the presence of significant bony pain may for early consultation.
suggest prostate cancer with bony metastases.
REFERENCES
The history should also elaborate on trauma, in{ections and bleeding disorders.Any recent ureLhral 1. Leary, F.J, Aguilo, JJ Clinical significance of hematospermia. Mayo Clin. Proc. 1974;49:815*817
instrumentation can give rise to haematospermia. The presence of dysuria and urethral discharge 2. )inza 5, Noguchi K, Hosaka M. Retrospective study of 107 patients with hematospermia. Hinyokika
will point towarcls UTly STDs. Concomitant macroscopic haematuria shc-uld usually prompt a referral Kiyo. 1997 Feb;43(2):103-7.
to the urologist.
56 AN APPRoACH To CoMMoN UROLOGICAL DIsORDERS i AN APPROACH TO HAEMATOSPERMIA AN APPROACH TO HAEMATOSPERMIA I AN APPROACH TO COMMON UROLOGICAL DISOROERS !
12 AN APPROAGH TO NON.TRAUMATIG UROLOGIGAL
The patient s i:ladder should be decompressed by inserting a transurethral 1 4 to 1 8F Foley catheter.
Urethral catheterization must be done under a sterile technique. After gently passing the catheter,
EMERGENCIES the balloon should be inflated with 10 ml of water. After catheterization, lt is crucial to reduce the
penile foreskin to its normal anatomic position to prevent the development of paraphimosis. lt is also
A,/Prof Weber Lau Kam 0n helpful to document the amount of residual urine drained and the colour of urine after catheterisation.
Senior Consultant, Depaftment of lJrology, Singapore General Hospital Occasionally, suprapubic catheterisation may be required in patientswho have a history of urethral
stricture or trauma, and this should be performed only by those experienced in the procedure.
WHAT ARE COMMON EMERGENCIES?
lf the patient is stable and comfofiable, he may be seen electively at the earliest possible urology
The family physician plays a very vital role in the early diagnosis and initial management of uroloqic
appointment. Ilowever, immediate referral to the emergency department is necessary in patients
emergencies as delay may result in significant pain and sequelae to the patients' who remain distressed despite catheterisation, are haemodynamically unstable. develop macroscopic
haematuria or fever with purulent urine.
The {ollowing are urological conditions that will need urqent treatment and referral to the urologist:
1. Acute ureteric colic ACUTE SCROTUM
2. Acute urinary retention
Acute scrotum refers to an acute painful swelling of the scrotum or its contents, accompanied by local
3. Acute scrotum signs or general symptoms. lt should be treated as an emergent condition requirinq prompt assessment.
4. Priapism Although there are many dif{erentials. the three commonest diagnostic possibilities are testicular torsion,
5. Paraphimosis epididymal orchitis. and appendage torsion.
6. Fourniers gangrene
Among these, the early recoqnition of testicular torsion is by far the most critical. The diagnosis
ACUTE URETERIC COLIC of testicular torsion should be based on clinical suspicion. Every case of acute scrotum should be
considered testicular torsion until proven otherwise. The age of the patient has limited value in
Ureteric colic is a complaint that often brings a patient to see the farnily physrcian. The nature of
discriminating between testicular torsion from other aetiologies of acute scrotum.
the loin pain is usually quite classicai. However, findings from physical examination are usually
unremarkable. Presence of peritoneal signs may point to other differential diagnoses such as
Typically. physical examination reveals a tender and asymmetrically high-riding testis on the affected side,
abdominal aortic aneurysm, diverticulitis, appendicitis, and gynaecologic disease that may mimic
with the long axis of the testis oriented transversely, or the epididymis may fre located anteriorly.
renal colir:.
Time is of the essence in this urological emergency since pain lasting more than 6 h is highly associated
A fever and sick-looking patient in whom there is a suspicion of in{ection with concomitant upper
wrth testicular death if ischemia is not relieved. Therefore, emergent surgical exploration is the treatment
urinary tract obstruction is an eme(gency. Resuscitation with inlravenous fluids should be immediate
of choice when the clinical suspicron for testicular torsion is strong.
and intravenous antibiotics started. Emergent referral to urology is needed as the obstructed kidney
miqht need to be drained percutaneously bv a nephrostomy. lvlost routine laboratory investigations cannot exclude testicular torsion. Doppler ultrasound examination
may be helpful only if it is readily available and to exclude epididymo-orchitis which usually can be
preliminary investigations such as urinalysis to look for haematuria and pyuria as well as a KUB X-ray
treated medrcally.
can be performed by the family physician. lf the findings of urinalysis are normal, one should consider
other differential diagnosis.
PRIAPISM
otherwise, in a stable patient, initial treatment with analgesia should be started in clinic Both Priapism refers to prolonged erection that is unrelated to sexual arousal. Although the corpora
inlramuscular and rectal NSAIDs such as indomethacin and intramuscular opioids are effective to cavernosa are typically rigid and filled with stagnant blood, the glans and corpus spongiosum
reduce the pain (1 ). However, patients experience more adverse etfecrs, such as vomiting,
when
rernarn tlaccid.
using opioids (particularly pethidine) than when using NSAlDs. Nevertheless, NSAIDs such
as
ketoiolac should be used cautiously in the elderly, patients with pre-existing renal diseases, and Priapism can be subdivided into low-flow and high{low variants b*ised on the penile arterial inflow
those with dehydration. state. High-flow priapism usually results from perineal or straddle trauma. Erection is usually partial
with little pain. As there is still continuous inflow of oxygenated arterial blood, patients with high-
l,/lost patients who respond to the conservative treatment may be sent home with oral
analgesia and
flow priapism suf{er less complications, and it is usually being managed conservatively first. Selective
referred electively to the urologist. Medical expulsive therapy, using tamsulosin or terazosin, can
be
angroembolization of the damaged central artery may be considered in refractory cases.
'lOmm to reduce pain and expedite stone passage (2). Patients
considered for patients with stones <
with intractable pain, {ever, nausea and vomiting and gross haematuria will require urgent urological Low-flow (ischemic) priapism rs painful and requires emergency treatment as delay intervention will
attention. result in ischaemic damage of the corpora cavernosa and permanent erectile dysfunction. The causes of
ischaemic priapism can be classified broadly into drug- related, neurologic, neoplastic and hematologic
ACUTE URINARY RETENTION causes such as sickle cell disease etc.
ftrll
Acute urinary retention is defined as the sudden inability to pass urine, which is associated with a
preceded by a history of
bladder and lower abdominal pain. tt is seen predominantly in men and usually
obstructive lower urinary tract symptoms. lt is usually secondary to bladder outlet obstruction
for which
include
the most common cause is benign prostatic hyperplasia. Other causes of acute urinary retention
prostate cancer and urethral Strictures.
53 AN APPROACH TO COM]MON UROLOGICAL DISORDTRS I AN APPROACH TO NON'TRAUMATIC UROLOGICAL EMERGENCIES ANAPPROACHTONON.TRAUMATICUROLOGIGLEMERGTNCIES IANAPPROACHTOCOMMONUROLOGICALDISORDERS 59
ln many cases of priapism, rf the presentation is early, conservative treatment such as physical exercise AN APPROACH TO IUON.TRAUMATIG UROTOGIGAL
(such as asking patients to climb stairs), or application of ice packs may eifect detumescence. lf these
measures fail, the next step is corporal blood aspiration. The aspirated blood should be sent for blood
EMERGEI'IGI ES: A FAM I LY PHYSICIAN'S PERSPEGfl UE
gas measurements to determine whether it is low-flow (low pH, low Po2, high Pco2) or highJlow
(normal pH. high Po2, Iow Pco2) states. lf it rs still not successful, warm salrne irngation and injection DrTung Yew Gheong
oi an alpha-adrenergic receptor agonist such as dilute phenylephrine (concentration of 0.1 to 0.5 mgl Consultant and Head, Toa Payoh Polyclinic,
'1
mL, and 1-mL injections made every 3 to 5 minutes for hour) should be attempted in patients with
National Healthcare Group Polyclinics
ischaemic priapism. Urgent surgical shunt procedures remained as a last resort if all measures fail to
Patients with non-traumatic urological emergencies frequently seek help from their Family physicians
result in detumescence.
as their first point of medical contact. While the collectlve incidence of non-traumatic urological
emergencies like acute ureteric colic, acute urinary retention, acute scrotum, priapism, paraphimosis and
PARAPHIMOSIS Fournier's gangrene is not high, the trmeliness and appropriateness of the initial management by Family
Paraphimosis occurs in situation when one fails to reduce the entrapped penile foreskin distally back to Physicians, not only potentially relieves pain, but also has an important bearing on the eventual clinicai
its usual position overlying the glans penis. This happens not infrequently to uncircumcised men after outcomes for this group of patients.
urinary catheterisation or clinical examination when the foreskin is not replaced to its normal position.
The tight distal foreskin forms a constricting band on the penile sha{t resulting in progressive glans ln the management o{ patients with urological emergencies, the Family Physician has the advantage
swelling due to impairedvenous and lymphatic drainage. This will further make reduction of foreskin of having the background knowledge of their patients' medical history, including the presence of any
distally more diff icult. underiying chronic diseases, past surgical history and medication history. Coupled with the privileqe of a
well-established doctor patient relationship, the Family Physician is in the ideal position to help patients
Treatment of paraphimosis is urgent reduction of the foreskin. Analgesia can be achieved by the with the initial rnanagement of their conditions.
applicatron of topical lignocaine gel, local penile nerve block or possibly conscious sedation. The glans
and penile tip are compressed with gloved hand to reduce the swelling so that the oedematous foreskin ln addition. with the rapidly aging population and longer life expectancy of our population, the
can be pulled distally, back to its natural position. Should this measure fails, a dorsal slit through the incidence of acute urinary retention in our population is expected to rise (1). Family Physicrans have an
paraphimotrc band should be performed. The patient should then be referred to the urologist for expanding role in helping to manage these patients within the community. For example, the simple
follow-up electively as circumcision may be indicated to prevent recurrence. office procedure o{ urethral catheterization in suitable patients can help bring immediate relief to
patients and avoirl a hospital emergency department visit. With the initial management performed at
FOURNIER'S GANGRENE (FG) the prinrary care level, an early outpatient uroloqy referral can then be arranged subsequently, bypassing
It is a rare but rapidly progressive form of necrotizing fasciitis which affect the perineum and exterrral genital
the busy emergerrry services.
area with possible involvement of the abdominal wall. The cause of FG is mainly polymicrobial aerobic and
anaerobic synerqistic infection with colorectal, genitourinary or skin as the primary infection site. lt should
REFERENCES
be considered in patients who are immuno-suppressed such as patients who are diabetics. alcoholic or 1. Meigs JB et al, lncidence rates and risk factors for acute urinarv retention:
on long term steroid. the health professionals follow up study. J. Urol. 1 999 Aug; 162(2):376-82
Clinically, tlre patient is usually febrile and toxic looking. The involved skin appears oedematous,
erl^hematous and indurated with crepitation. There may also be skin necrosis, or blistenng with purulent
collection. Despite a multidisciplinary approach that includes active resuscitative support, intravenous
broad-spectrum antibiotics, followed by early aggressive surgical debridement of all involved tissues, the
mortality rates are still very high.
REFERENCES
1. Holdgate A. etal. Nonsteroidal anti-in{lammatory drugs (NSAIDS) versus opioids for acute renal
colic. The Cochrane Library issue 1 2009.
2. Christian Seitz a. et al., Medical Therapy to Facilitate the Passage of Stones: What ls the
Evidence? European Urology 56 \2009) 455 - 47 1 .
graduJl, unlike the more precipitous decline in estrogens levels experienced by women during safe and can improve the quality of life of patients with LOH.
i,"noprrru. This can lead to a clinical condition known as late onset hypogondadism (LOH).
C ontra i nd ications:
Testosterone has wide ranqinq actions beyond its reproductive functions. lt preserves bone and 1. Patients with prostate or breast cancer
muscle mass, stimulates red blood cell formation and acts on mental functions such as rnood 2. Significant erythrocytosis with haematocrit levels of > 52%
and energy. 3. Known liver dysfunction
Clinical manilestations
'l
. Lower urinary tract symptoms suggestive of significant bladder outlet obstruction from benign
These include: prostatic hyperplasia
'1. Diminished sexual desire and erectile quality, particularly nocturnal erections 2. Obstructive sleep apnoea
2. Chanqes in mood and drive, leading to decreased intellectual capacity, fatigue, depressed mood
Metabolic syndrome and low testosterone:
and irritability
3. Decrease in lean body masswith associated reduction in muscle mass and strength
There is increasing evidence of a relationship between metabolic syndrome and low serum testosterone.
4 Decrease in body hair and skin alterations Some early interventional studies in hypogonadal men have shown beneficial effects on improving
5. Decreased bone mineral density resuliing in osteopenia and osteoporosis obesity, lipid profile and glycaemic control. However. in the recent past, the lnternational Society for
6. lncrease in visceral fat the Study o{ the Ageing Male (ISSAM) recommended caution in thc use of testosterone replacement
in patients with significant cai'diovascular risk factors. Until the results of ongoing long term studies
Not all of these manifestations need to be present for the diagnosis to be ttiade. Further- become available, the utility of testosterone replacement to improve metabolic profrle in hypogonadal
more, some manifestations may be more prominent than others in individual patients. men is not proven.
Blood investigations Prior to commencing therapy, the following should first be estalished:
Diagnosis is mJe when clinical manifestations of LoH are supported by biochemistry suggestive
of
1. Serum prostate specific antigen (PSA)
restosterone deficiency. However, there is no current consensus on the serum level of testosterone
specific
2. l-laematocrit (Hct) level
at which a particular patient would be diagnosed with LOH. Furthermore, age and ethnicity
J. Lrver lunctron tesl (L l- I )
reference ranges have also not been fully established. Wide irrter-individlral variation have also been
observed in asymptomatic individuals.
4. Fasting lipid profile
(fi) Thyroid function test should also be done to exclude hypothyroidism which may
1. Total testosterone
mimic or coexist with LOH symptoms.
Testosterone level varies tlrroughout the day as a result o{ the circadian rhythm. The best time
for serum measurement is in the morning from 0700 hours to 1 1 00 hours. Estimation of total
testosterone levels is readily available in most laboratories but results need to be intepreted with
(SHBG) may result
caution. ln the elderly and the obese, elevations of sex hormone binding globulin
in seemingly normal TT levels, despite the patient being hypogonadal (false negative result). However,
in the preience of suggestive LOH symptoms, TT levels below 10 nmol/L may warrant a trial
of
therapy after a discussion of the risks and benefits. With equivocal levels of 1 0-1 5 nmol/l, further
tests are advised.
bindini globulin (SHBG) and albumin. Direct measurement of FT is not readily available in most
laboratories.
2.5-7.5m9 daity
NormaITT
Transdermal Testosterone patches Androderm
Testoderm l0-l5mg/daily
Testosterone gel Androgel 5'10q
I 7o atkytated testosterone preparations ftuoxymesterone and methyttestosterone are both assocrated with serious
liver toxicity: i-m., instramuscularty
WHEN IS A REFERRAL TO THE UROLOGIST INDICATED ? Start reptacement therapy lnvestigate pituitary Seek other causes
1. Low normal/ low FSH and LH levels, which are suspicious for hypogonadotrophic hypogonadism.
This may be due to a pituitary cause for low serum testosterone levels
2. Raised PSA or abnormal digital rectal exam which may suggest prostate cancer REFERENCES
3. Symptoms suggestive of srgnificant BPH which may worsen during testosterone replacement 1. "lnvestigation, treatment and monitoring of late-onset hypogonadism in males
4- Poor response to initial testosterone therapy - Official Recommendations of The lnternational Society for The Study of the Ageing Male
(SSAM)".A. Morales and B. Lunefeld. The Aging Male 2002;5:74-86
2. Singapore Urological Association * 6uidelines on Late Onset Hypogonadisr-l
3. Urology and the Family Physician Ed M Wonq and Foo KT.
The approachto late onset hypogonadism (LOH) in men consists of recognising the condition, work
up, and management. WHAT ARE RENAL CYSTS?
Renal cysts are fluid-filled structures in the kidney that are not continuous with the nephron or collecting
RECOGNITION system. They can occur in a variety of diseases in adults and children. With the advent and availability
o{ imaging in modern medrcine, the incidental finding of renal cysts is a common occurrence in the
The triad of sexual symptoms, identified by the European Male Aqeing Study (EMAS)(1), is useful:
outpatient setting. Renal cysls may arise in 3 most common scenarios: incidental simple cysts, autosomal
. Decreased frequency of morninq erectlon,
dominant polycystic kidney disease and acquired cystic disease in patients with end-stage renal disease
. Decreased frequency of sexual thoughts, and on dialysis. Regardless of the setting, the primary clinical concern is accurately distinguishing simple
. Erectiledysfunction. renal cysts from complex renal cysts that may harbour neoplastic masses.
LOH patients may alsc present with less specific symptoms: decreased vitality, decreased mood, WHAT ARE 'SIMPI-E RENAL CYSTS'?
decreased muscle mass and strength.
WORK UP
History - The history workup needs to consider the differential diagnosis:
. Erectile dysfunction - this could be due to hypogonadism alone; be part of a metabolic
syndrome e.g , diabetes mellitus, hypertension, obesity; or a harbinger of cardiovascular
disease; smoking and stress also result in erectile dysfunction.
. Weight loss and sarcopenia - Exclude other reasons besides hypogonadism.
n Mood changes, lethargy, and weakness - Exclude depression.
. Statin therapy * This can result in low testosterone and hypogonar:lism (2).
MANAGEMENT
Do total testosterone (TI) as the initial screening investigation and manage according! (3) :
. 3. Lunenfeld B, Arver S, Moncada l. Rees DA, Schulte HM. How to help the aging male? Current
approaches to hypogonadism in primary care. Aging Male. 201 2 Dec;15(4):1al-91 '
Patients with end-stage renal disease on dialysis form a specific population at risk for development Affected patients may present with flank pain or renal insufficiency, and hypertension. Cysts may
alscr
of multiple renal cysts. The incidence of acquired cystic kidney disease increases with the duration be seen in the liver and pancreas. Hepatrc cysts, tor example, can be detected in over iralf
of the
of dialysis (2.3). lt is well reported in the literature that the risk of developing renal cell carcinoma cases and ai'e more ccmmonly seerr in women and in patients over 40 years of age (g). Additional
increases dramatically in patients with acquired cystic kidney disease (3-7), hence many of these manifestations rnay include intracranial arreurysms, decreased urinary concentrating ability, and
patients are on surveillance imaging by the renal physicians. abdominal wall hernias (1 1).
ln up to 25 per cent o{ patients, both clinical presentation and imaginq would suggest a diagnosis of
ADPKD, but there is no family history of the entity. The majority of these cases arelnherited, and it is
most likely that the affected parent has passed away without a formal diagnosis. lt is also possible
that
the parent has a subclinical form of disease not clinically apparent yet. ln a very small percentage of
patients. it may be trLlly a sporadic new mutation.
58 AN AppRoACH To coMMoN uRoLocrcAt DtsoRDERs I AN AppRoAcH To RENAL cysrs AN APPROACH TO NENAL CYSTS I AN APPROACH TO COMMON UROLOGICAI. DISORDERS 59
Management is largely conservative in nature and patients are usually given anti-inflammatory analgesia
The two most common organs involved are the kidney and the liver. The kidneys are increased in size
and a course of antibiotics to prevent infection from setting in. As haemorrhagic cysts resolve, they
with muhiple microcysts. The severity of the renal disease is proportional to the number of nephrons
develop residuai calcification in a central pattern or within the cyst wall that becomes thickened and
affected by the cysts. This entity is always associated with some degree o{ congenital hepatic fibrosis
develop septae with the cyst becoming multilocular or multilobulac essentially acquiring the features of
(1 2). Over time, hepatomegaly and portal hypertension ensue in most patients.
a complex cyst.
as incidental findings on ultrasound or CT performed to evaluate other conditions. The management Simpte cyst with hairtine thin watL
of cysts is guided by the Bosniak classification (Table 1 ). lndeed, not all renal cysts have to be No septa, catcification or solid components
referred to the urologists. The management of symptomatic patients is however different and larqely No enhancement, water consistency
depends on the cause for their symptoms. These patients may present with complications from I Septar few hairLine thin, no measureable enhancement
the renal cyst such as infection, hemorrhage or rupture and witl often need to be treated at the Catcification: fine or short segment may be present in wat[ or septa
Unifo.mty high attenuating cysts l.3cml that are welt marginated and
tertiary setting. Apart frorn becoming symptomatic, cysts that develop complications may acquire non-enhancing are inctuded-
radiological features that mimic malignancy and require careful evaluation and follow-up. One must Generatly welt marginated
also be rnindful to screen the family menrbers upon the possible diagnosis of inherited polycystic
kidney disease. ilF Septa: muttipLe thin hairlino, no enhancement
Minimat thickening of watl or septa which may contain calcification that may be
thick and nodutai no measureable enhancement
WHAT ARE THE COMPLICATIONS OF REIIIAL CYSTS? Totatty intrarenaL high attenuating non-enhancing rencI tesions >3cm are included
Complications are rare with a reported range of 2 to 4%. The principal complicatiorrs are ilt Measurabte enhancement 40-60./"
hemorrhage, infection, or rupture. Such cases in general should be refered for further evaluation lndeterminate Cystic mass with thickened smooth or irregutar watts or septa with
measurabte enhancement
and treatment (1 3).
Ctearty matignant cystic lesions that have alt of the features oflll with enhancing B5-100%
Pain Matignanl soft tissue components adjacent to but independent of the watt or septa
pain is the most common symptom associated with renai cysts and probably results from distention
c,f the renal capsule, but may also be a secondary effect due to obstruction of the collecting system.
Oral analgesia can be prescribed if no contraindications.
Obstruction
Cysts cause some degree o{ collecting system obstruction in certain cases. Parapelvic cysts may
obstruct the ureter o; low pelvis, whereas peripheral cortical cysts can cause infundibular or calyceal
obstruction. lf there is any eviclence of obstructive uropathy, the patient should be re{erred for
furttter treatment.
Rupture
Cyit rupture can be a source of significant pain. Rupture can occur due to blunt trauma or increased
intracystic pressure in the setting of intracystic hemorrhage or infection. Haematuria is seen in
up to 80% of patients with cyst rupture, likely resulting from cyst rupture into an adjacent calyx.
Less commonly, cysts can rupture through the renal capsule and cause a perirenal urinoma or
haematoma.
liaemorrhage
Haemorrhage may occur in a pre-exlsting simple cyst, or a cyst may form from the liquefaction of
a traumatic haemorrhage within the kidney parenchyma. Approximately 6% of simple cysts are
complicated by haemorrhage, usually as a result of trauma, enlargement, or bleeding diathesis.
CATEGORY gIF
Category llF cysts deserve follow-up imaging (hence the "F") to document stability. A tollow-up
ultrasourrd can be clone in \/hich the absence of change supports benign disease. while progressron
raises suspicion oi a neoplastic process. in which case, a cr Kidneys can be done to confirm the
findings. When foilouring Lrp a patient for a Bosni.:k llF cyst, it is important to obtain prior studies for
purposes of comparison. lf such studies are unavailable, an additionai imaging stutiy shoLtld be ordered
for f urther characterisation.
Frgure 5. Bosniak Classification
CATEGORY IAND II
Further evaluation of Bosniak category I and ll lesions is generally not required. However, in certain
instances, repeat Lrltrasonography at 6 to 1 2 months to assure
CATEGORY iUI
The management of Bosniak category lll lesions is controversial. Some authorities recommend that all
Bosniak category lll lesions undergo surgical evaluation, given the high incidence of malignancy (40 to
60 percent) with these findings. ln addition, if the radiologist is unable to clearly distinguish a caiegory
Figure 6. Bosniak I Cyst (arrowed)
llF {rom a lll lesion, it should be placed in a higher category, particularly if a partial nephrectomy is
anatomically possible.
72 ANAPPROACH ToCoMMoN I}RoIoGIcAI DISoRDFRS I AN APPROACH TO RENAT CYSTS AN APPROACH TO RENAL CYSTS I AN APPROACH TO COMMON UROLOGICAT DISORDERS 7
on the other hand, there would be a significant number of unnecessary operations with such an REFERETICES
approach, since a signi{icant percentage of patients with indeterminate iesions have benign lesions.
1. Lippert, MC, Renal Cystic Disease, Adult and Pediatric Urology, 4th ed, Gillenwater, lY, Grayhack,
JT, Howards, SS, Mitchell, N/E (Eds), Lippincott, Williams & Wilkins, Philadelphia, 2002, pp. 8589
we may offer the patient two additional modalities, CT Kidneys and Contrast-
To avoid this situation,
enhanced Ultrasound of the kidneys. 2. lshikawa l. Acquired cystic disease: mechanisms and manifestations. Semin Nephrol 1991;11:671.
3. Matson MA et al. Acquired cystic kidney disease: occurrence, prevalence, and renal cancers.
..:::Br ,-.{ ' 1;
Medicine (Baltimore) 1990: 69:217.
4w'
4. Kojima Y et al. Renal cell carcinoma in dialysis patients: a single center experience. lnt J Urol 2006;
ll 1 3:1 045.
I 5. Farivar-Mohseni, H et al. Renal cell carcinoma and end stage renal disease. I Urol. 2006 175-2018.
6. Chandhoke PS et al. Acquired cystic drsease of the kidney: a management dilemma. J Urol 1992;
147:969.
7. Denton MD et al. Prevalence of renal cell carcinoma in patients wlth ESRD pre-transplantation: a
pathologic analysis. Kidney Int 2002; 61 2201.
8. Bae KT et al. Magnetic resonance rmaging evaluatron of hepatic cysts in early autosomal-dominant
polycystic kidney disease: the Consortium for Radiologic lmaging Studies of Polycystic Kidney
Disease cohort. Clin J Am Soc Nephrol 2ooq 1:64.
9. Patel V et al. Advances in the pathogenesis and treatment of polycystic kidney disease. Curr opin
Nephrol Hypertens 2009; 18:99.
10. Wilson PD. Polycystic krdney disease. N Engl J Med. Jan 8 2004;350(2):151-64.
1'1 . Pirson Y. Extrarenal Manifestations of Autosomal Dominant Polycystic Kidney Disease. Adv Chronic
Kidney Dis. Mar 201 0;1 7(2): 1 73-1 80.
12. Gunay-Aygun M et al. Autosomal recessive polycystic kidney disease and congenital hepatic
fibrosis: summary statement of a first National lnstitutes of Health/Office of Rare Diseases
conference. I Pediatr. Aug 2006;'149(2):1 59-64.
Category lV lesions invariably require surqery, wrth appfoxrmately 85 to 100 percent being
1 5. Curry NS et al. Cystic renal masses: accurate Bosniak classification requires adequate renal Cl AJR
Am J Roentgenol. 2000:1 75(2):339.
malignant'l 5-1 7. These lesions should be treated as malignant entities and be investigated
accc,rdingly with staging CT. chest x-ray and bone scan if necessary.
1 6. Bosniak MA. The small (less than or equal to 3.0 cm) renal parenchymal tumor: detection,
diagnosis, and controversies. Radiology. 1991:179(2):307.
1 7. Bosniak N4A. Tlre current radiological approach to renal cysts. Radiology. 1 986;1 58( 1 ): 1 .
AN APPROACH TO COMMON UROLOGICAL DISORDERS I AN APPROACH TO RENAL CYSTS AN APPROACH TO RENAL CY5T5 I AN APPROA'H TO IJROTOG AL DISORDERS 75
'OMMON
'1.
Diagram Suggested flowchart {or management of Renal Cysts
RENAL CYSTS: A FAMIIY PHYSICIAN'S PERSPEGIIUE
Dr Hwang SiewWai
Director & Family Physician, Consultant, SingHealth Potyctinics - Bukit Merah
The majority of renal cysts encountered in the polyclinic come from incidental findings of
imaging studies, such as during annual ultrasound surveillance of the liver in chronic Hepatitis B. These
patients are generally well with an unremarkable history and physical examination
but 'red flag' symptoms o{ fever, werght loss, haematuria or flank pain should be enquired for.
The Bosniak classification has been mentioned as a useful guide to the need for further evaluation of
a renal cyst. This classification, however, is based upon CT findings (such as the presence of contrast
enhancement irom the lesion) and may have limited usefulness in the polyclinic as the diaqnosis of a
renal cyst in the polyclinic setting is frequently based on ultrasonic examination (that is typically not
contrast enhanced).
Simple cysts are most commonly found. On ultrasonography, simple cysts appear well defined
wrth a spherical or ovoid shape and possess a thin smooth wall distinct from the surrounding renal
parenchyma. There is no septum or calcification within these cysts. Sound waves are well transmitted
and internal echoes are absent.
ln clinical practice. patients with simple cysts can be reassured that no fllrther investigation or treatmenl
is requireci. lt is good practice to pre-empt patients to seek medical attention in the rare event of fever,
flank pain, abdominal pain or haematurra- Another option is to repeat an ultrasouncl examination in 6
months to ensure that there is no change in size or consistency of thls cyst. This ultrasound scan can be
ordered dii'ectly bv the polyclinic doctor.
I would refer patients with large cysts (size greater than 3cm) or complex cysts to a urologist
to exclude the possibility of malignancy,. Features o{ complex cysts include calcification, multi-loculation,
thickened walls or thickened septa.
76 AN AppRoAcH To coMMoN uRoloctcal DtsoRDtRs I AN appRoAcH To RENAL cysrs AN APPROACH TO RENAI. CYSIS I AN APPROACH TO COMMON UROLOGICAL DISORDERS 7i
15 AN APPROAG}I TO THE EUATUATION OF GOMMON
Clinical examination will reveal a hard to firm, non-tender irregular testicular mass. Adjacent structures
such as the sperrnatic cord and scrotal skin may be involved. Systemic examination may reveal
SGROTAL GONDITIONS lynrphadenopathy and gynaecomastia.
Dr Lee Fang Jann Scrotal ultrasound is the first line investigation to confirm the diagnosis. A CT of the abdomen and chest
Consultant, Department of Urology, Singapore General Hospital is crucial for staging. Serum tumour markers such as beta-hunlan chorionic gonadotrophin and alpha-
fetoprotern help to prognosticate risk. lt is also useful for follow-up in selected tumour subtypes.
HOW DO IAPPROACH SCROTAL SWELLINGS?
An <irchiectomy is therapeutic in localized disease, and histology will confirm the tumour subtype.
Scrotal swellings can range from benign congenital conditions to malignancies and surgical
Additional adjuvant chemotherapy or radiation therapy may be required. A high cure rate of 95% is
emergencies. A good history and physical examination, together with an understanding of the scrotal possible with low stage cancer.
anatomy helps accurately differentiate most lesions.
EPIDIDYMIS
TESTES
Epididymitis/Epididymo-orchitis
Torsion The condition is most common in the young adult. lt may or may not be related to a prior sexual
Torsion of the testicle is a disease process whereby there is cessation of blood to the testicle due to a
encounter. The pain and swelling is usually indolent in onset but may be difficult to differentiate from
twisting of the testicular artery (and associated structures). Testicular torsion occurs most frequently torsion. A history of urinary tract infection, urinary catheterization or urinary tract surgery should be
between the ages of 1 0 and 30, with a peak at the age of 1 3 to 1 5 years, but any age group may be sought. The offensive pathogens are usually bacterial. Chlamydia trachomatis and Neisseria gonorrhea
affected. The left side rs affected more often than the right. Torsion of both testes can occur in 27o should be considered rn the sexually active patient.
o{ boys.
On physical examination, localised epididymal or generalized scrotal tenderness may be elicited. The
The classical presentaticn is one of acute pain and swelling in the ipsilateral hemiscrotum waking the
cremasteric reflex is usually present. Urinalysis will show pyuria and a urine sample should be collecied
patient from sleep. There may be referred pain to the lower abdomen. Nausea and vomiting may
for culture.
accompany the painful condition. Unnary symptoms such as dysuria and urgency are usually absent.
lf the patient permits physical examination, one will find a firm testicle riding high in the scrotum
A Doppler ultrasound will demonstrate increased blow flow in the affected testes. The treatment
with an abnormal trarrsverse lie (1).'l-he cremasieric reflex is usually absent and elevation of the
consists of scrotal elevation, analgesia and a course of broad spectrum antibiotics. Fluoroquinolones are
testicle aggravates the Pain (2). advantageous as they have a good penetratron of the urinary tract. A two weeks course of doxycycline
should be adrninistered concurrently in those suspected with C. trachomatis infection. The partner
This is a surgical emergency as the testicular salvage rates depends on the duration of ischemia, with
should also be treated in view of a high risk of cross-infection.
a 9O7o salvage rate within the first 6 hours. This drops to 500/o after 12 hours, and to only 10% after
24 hoirrs (3-5). Spermatocele
This is a sperrn-contarning retention cyst rn the epididymis. lt is usually painless and presents as a self
lf the clinical suspicion is high, immediate surgical exploration is mandatory. Doppler ultrasound and detected nodule in the head of the epididymis. Ihis can be felt above. behrnd and separate from the
testicular radionuclide scanning to assess blood flow to the testicle may be offered to patients in testis. lt does not transilluminate. They are most common in men above the age of forty.
equivocal cases if they can be obtained in a timely manner. Spermatocelectomy can be offered to those with bothersome symptoms. This should be delayed if
preservation of fertility is important .
Surgery consist of surgical detorsion and bilateral orchidopexy. A gangrenous testicle will have to
be removed. Leaving a non-viable testicle in-situ puts the patient at risk of developing subsequent Pampiniform plexus
orchalqia, infectiorr and leads to the theoretical risk of production of antisperm antibodies as the A varicocele refers to abrnormal enlargement of the veins draining the testis. Most varicoceles are
blood-testis barrier is broken down. diagnosed in the teens or early adulthood. They rarely develop after the age of 40 years. They occur in
'I 5% of males. Causes of varicoceles
lnclude incompetent valves ang[ proximal venous obstruction. They
Torsion o{ the appendix testis usually presents similarly to testicular torsion. lf examination is occur more frequently on the left sjde.
performed early in the course before edema sets in, one will be able to feel a smalltender lump at
the superior pole of the testicle. A blue dot sign may be seen through the scrotal skin, corresponding The typical presentation is a dull, dragging ache in the affected scrotum. The symptom increases over
to the ischemic appendage. the course of the day and is exacerbated by exertion. Physical examination will reveal a "bag of worms"
around the spermatic cord that disappears when the patient is supine.
The treatment consists of supportive care with nonsteroidal analgesia atld rest. ln uncertain cases,
exploration is recommended to rule out testicular torsion. The diagnosis can be confirmed on scrotal ultrasound. Varicocelectomy should be offered to
symptomatic individuals, and those with the sequelae of testicular atrophy or subfertility.
Testicular Cancer
Testicular cancer is the most common cancer rn men age between 5 and 35 years old. lt comprises
'1
1-2% of all male malignancies but causes 127o of cancer death in men between the ages of 20 to SPERMATIC CORD
35. Germ cell tumours occur most commonly between the ages of 20 to 40. Lymphoma is more Hydrocele
common over the age of 60. A history of cryptorchidism is a risk factor. A hydrocele is a collection of fluid around the testis or spermatic cord. lt is caused by fluid secretion
from the tunica vaginalis that envelopes the testis. lt occurs in 1 % of males. Hydrocele can also be
The patient usually presents with a painless scrotal swelling. An episode or trauma may lead to self reactive and secondary to a trauma, inflammation or tumout
examination and detection of the mass. Late stage disease may have associated systemic symptoms
of weight loss and leg swelling.
AN APPROACFI TO COMMON UROLOGICAL DISORDERS I AN APPROACH TO THE EVALUATION OT COMMON SCROTAL CONDITIONS AN APPROACH TO THE EVALUATION OF COMMON SCROTAL CONDITIONS I AN APPROACH TO COMMON UROLOGICAT DISORDTRS 79
The patient usually presentswith painless swelling of the scrotum. There will be a smooth scrotal
swelling on examination that prevents palpation of the testicle within. Transillumination will usually
clinch the diagnosis and one can get above the mass.
An ultrasound will exclude any underlying testicular pathology. Simple asptratron will afford
temporary relief, but re-accummulation of the {luid is common, as the tunica vaginalis produces
0.5mls o{ fluid per day. A more definite treatment consists o{ open hydrocelectomy and allowinq fluid
reabsorption by the scrotal lymphatics.
lnguinal hernia
A persistent processus vaginalis may lead to an indirect inguinal hernia. The hernia foliows the path
of the processus vaginalis through the inguinal canal into the scrotum. This leads to a presentation
with an indirect inquinal hernia.
The typical presentation is an rnguinal or scrotal swelling that fluctuates in size. Physical exertions
or Valsalva maneuvers ygill exacerbate the swelling, while resting in a supine position makes it less
obvious.
Physical examination may reveal an inguinal-scrotal mass that can be felt separate from the normal
scrotal contents. The hernia can often be reduced unless it is incarcerated.
Strangulated hernias will be painful and examinatlon will demonstrate tenderness. There may be
associated nausea, vomiting and lower abdominal pain in keeping with bowel obstruction and
in{arction. This represents a surgrcal emergency and the need for urgent repair.
REFEREI{CES
1. Kadish, H.A. and R.G. Bolte, A retrospective review of pediatric patients with epididymitis,
testicular torsion, and torsion of testicular appendages. Pediatrics, 1 998. 1 02(1 Pt 1 ): p. 73-6.
2. Rabinowitz, R., The importance of the cremasteric reflex in aLute scrotal swelling in children. .l
AN APPROACH TO THE EVALUATION OF COMMON SCROTAL CONDITIONS AN APPROACH TO COMMON UROLOGICAL DIsORDERS
80 AN APPROACH TO COMMON UROLOGICAL DISORDERS I AN APPROACH TO THE EVALUATION OT COMMON SCROTAT CONDITIONS I
The patient usually presents with painless swelling of the scrotum. There will be a smooth scrotal
swellinq on examinatjon that prevents palpation of the testicle within. Transillumination will usually
clinclr the diagnosis and one can get above the rnass.
An ultrasound will exclude any underlying testicular pathology. Simple aspiration will afford
temporary relief, but re-accummulation of the fluid is common, as the tunica vaglnalis produces
0.5mls olfluid per day. A more definite treatment consists of open hydrocelectomy and allowing fluid
reabsorption by the scrotal lymphatlcs.
lnguinal hernia
A persistenr processus vaginalis may lead to an indirect rnguinal hernia. The hernla follows the path
of the processus vaginalis through the inguinal canal into the scrotum. This leads to a presentatiol.)
with an indirect inguinal hernla.
The typical presentation is an inguinal or scrotal swelling that fluctuates in size. Physical exertions
or Valsalva maneuvers will exacerbate the swelling, while resting in a supine position makes it less
obvious.
physical examination may reveal an inguinal-scrotal mass ihat can be felt separate from the normal
scrotal contents. Tlre hernia can often be reduced unless it is incarcerated
Strangulated hernias will be painful and examination will demonstrate tenderness. There may be
associated nausea, vomiting and lower abdorninal pain in keeping with trowel obstruction and
infarction. This represents a surgical enlergency and the need for urgent repair'
REFERENCES
1. Kadish, H.A. and R.G. Bolte, A retrospecttve review of pediatflt patients with epididymitis.
testicular tolsion, and torsion of testicular appendages. pediatrics, 1 999. 1 02( 1 pt i ): p. 73-6.
2. Rabinowitz, R., The importance of the cremasteric reflex in acute scrotal swelling in children. J
Men from puberty onwards should examine monthly their testes after a hot shower or bath, when on the fundampntal principles of a good composition and perspective, the artist would prioritrze the
the scrotum is loose (1) and while standing (2). They should first examine each testicle separately, details accordingly, so as to produce a pleasing composition. lt is not possrble or desrrabie to include all
feeling for lumps and then compare them to see whether one is larger than the other. Testicular the details, and the artist needs to prioritize what is important and what is so, in order to give a goocl
pain can be referred from the abdomen or radlcular pain from thoracolumbar spine. notably a di;c balance to the art piece.
disruptionattheTl2-11 level involvingtheLl root(3).Considerdissectinganeurysminanolder
persorr presenting as a testicular torsion (3). ln real life clinical practice
4 Firstly, the clinician needs to consolidate the evidence and facts that he has accrued from clinical
TORSION evaluation of the patient (from history, physical examination and investigations). This needs to be
integrated with background information from the literature.
Torsion of the testes is the most common cause of scrotal pain in infancy and childhood (3). Torsion
of the testes should form part of the di{ferential diagnosis in a boy or young man who is vomitlng Secondly, he needs to see the whole picture, based on his understanding of the pathology and natural
and has intense parn in the lower abdominal quadrant inguinal region (3).Suspect self-correcting hrstory of diseases, and to predict the future course of events for that particular patient.
testicular torsion in repeated episodes of severe spontaneous pain.
Refer [or orchidopexy (3).
Thirdly, he would need to balance the risks and benefits of treatment, so as to achieve balanced and
cost-effective management- all done in the best interest of the patient.
EPIDIDYMO-ORCH!TI5
The clinical picture of epididymo-orchitis can mimic torsion of the testes so closely', in most children; Therefore, in ihe process of formulating clinical guidelines for practicing clinicians, althouqh there is a
the diagnosis should be made orr surgical exploration (4). Patients who fail to respond to treatment need to gather all published evidence, it is not necessary to include all the details. It would be ttre job
{or epididymo-orchitis should be reassessed {or abscess formation or testicular cancer (3). of the committee to decide what is more important and what is less so. lrrhich. in effect, would be to
prioritize information. l'his would be based on both the dccuracy and the practicality of the tests or
TESTICULAR CANCER parameters available. For example, digital rectal examination (DRE) with ultrasound (trarrs-abdonrinal
The development of an acute hydrocele should be regarded with suspicion (3). Beware of the or trans-rectal) can easily and preciseiy evaluate patients with lower urinary tract symptoms. lt can
strangulated inguinoscrotal hernia presenting as a testicular torsion (3). Men with a history of also diagnose clinical benign prostatic hyperplasia and assess the prostate volume. Although magnetic
testicular cancer should be educated to watch for symptoms of cardiac disease and reduce their resonance imaging may offer more accuracy. it would not be practical rn real life practice due to cost
risk through lifestyle modification. Chemotherapy recipients are also at a higher risk of leukemia, and logistics issues.
secondary non germ-cell tumours, including lun9, biliary, gastrointestinal, bladder, and stomach
cancers. and sarcomas. Thus patients must be counseled on these risks and go for regular periodic Hence, usrng trans-abdominal ultrasound to assess the size and the shape of the prostate (ie. intravesical
prostatic protrusion-lPP) would be practical for most urologists. This would be a more balanced
health checks. They should also be counselled not to ignore any red flags pertinent to these
conditions (5). approach as trarrs-abdominal ultrasound is rron-invasive (compared to the
trans-rectai route), and easy to perform. The IPP is no1 only diagnostic but also predictive of the severity
REFERENCES and rate of progression of bladder outlet obstruction.
82 AN APPRoACII To coMMoN URoLoGIcAL DISoRDER5 I AN APPXOACH TO THE EVALUATION OT COMMON SCROTAL CONDITIONS ART AND REAL LIFE CLINICAI PRACTICE IANAPPROACHTO COMMON UROLOGICALD|SORDERS 8