SYMBOLS AND ABBREVIATIONS xxvii MS MSA MSK MSU mSV MUCP MUI MUSE MVAC Na+ NA NAAT NaCl NAION NB NBI NDO NE ng NGU NICE NIDD K multiple sclerosis multisystem atrophy medullary sponge kidney mid-stream urine milliSevert maximal urethral closure pressure mixed urinary incontinence Medicated Urethral System for Erection methotrexate, vinblastine, adriamycin, cisplatin sodium noradrenaline nucleic aci d ampli \201 cation test sodium chloride non-arteritic anterior ischaemic optic nerve neur opathy nota bene (take note) narrow-band imaging neurogenic detrusor overactivity nocturnal enuresis nanogram non-gonococcal urethritis National Institute for Health and Clinical Exc ellence National Institute of Diabetes and Digestive and Kidney Diseases National Institute of Health National Institute of Health Chronic Prostatitis Symptom Index nanometer non-mon osymptomatic nocturnal enuresis nanomole nuclear matrix protein number needed to detect num ber needed to treat nitric oxide nocturnal polyuria non-steroidal anti-in \202 ammatory dr ug non-seminomatous germ cell tumors non-speci \201 c urethritis non-visible haematuria om ni die (once daily) overactive bladder oligoasthenoteratospermia onlay island \202 ap NIH NIH-CPSI nm NMNE nmol NMP NND NNT NO NP NSAID NSGCT NSU NVH od OAB OAT OIF SYMBOLS AND ABBREVIATIONS xxviii OLND OP OSA Pabd PAOD PaCO2 PaO2 PAG PAIS PBS/IC PC PCNL PCO2 PCR PCT PD PDD PDE5 Pdet PDGF PDT PE PEC PEP PESA PET PFMT PFS PGE1 PGF2 PIN PLAP PLESS PMC PMNL PN PNE PO PO2 POP POPQ PPS obturator lymphadenectomy open prostatectomy obstructive sleep apnoea intra-abdominal press ure peripheral artery occlusive disease partial pressure of carbon dioxide (in arterial blo od) partial pressure of oxygen (in arterial blood) periaqueductal gray matter Partial andro gen insensitivity syndrome painful bladder syndrome/interstitial cystitis prostate cancer p ercutaneous nephrolithotomy carbon dioxide tension polymerase chain reaction proximal convo luted tubule Parkinson \200\231s disease photodynamic detection phosphodiesterase type-5 de trusor pressure platelet-derived growth factor photodynamic therapy premature ejaculation o r pulmonary embolism perivascular epithelioid cell post-exposure prophylaxis percutaneous e pididymal sperm aspiration positron emission tomography pelvic \202 oor muscle training p ressure \202 ow studies prostaglandin E1 prostaglandin F2 prostatic intraepithelial neopl asia placental alkaline phosphatase Proscar Long-term Ef \201 cacy Safety Study pontine mi cturition center polymorphonuclear leukocytes partial nephrectomy peripheral nerve evaluati on orally (per os) oxygen tension pelvic organ prolapse pelvic organ prolapse quanti \201 cation pentosan polysulphate sodium SYMBOLS AND ABBREVIATIONS xxix PR PREDICT PRP PSA PTFE PTH PTN PTTI PTNS PUJ PUJO PUNLMP PUV PVD Pves PVN PVN PVP PVR QALY qds Qmax QoL RBC RBF RCC RCT RFA RI RNA RP RPD RPF RPLND RPR RR RT RTA RTK s SARS SC pulse rate Prospective European Doxazosin and Combination Therapy prion protein prostate sp eci \201 c antigen polytetra \202 uoroethylene parathyroid hormone levels posterior tibia l nerve parenchymal transit time index posterior tibial nerve stimulation pelviureteric jun ction pelviureteric junction obstruction papillary urothelial neoplasm of low malignant pot ential posterior urethral valves peripheral vascular disease intravesical pressuer paravent ricular nucleus peripheral vascular disease photoselective vaporization of the prostate pos t-void residual quality-adjusted life year fourth die sumendus (to be taken 4 times per day ) maximal \202 ow rate quality of life red blood count renal blood \202 ow renal cell c arcinoma randomized control trial radiofrequency ablation resistive index ribonucleic acid radical prostatectomy renal pelvis diameter retroperitoneal \201 brosis or renal plasma \202 ow retroperitoneal lymph node dissection rapid plasma regain respiratory rate radioth erapy renal tubular acidosis receptor tyrosine kinase second sacral anterior root stimulato r subcutaneous SYMBOLS AND ABBREVIATIONS xxx SCC SCI SCr SEM SHBG SHIM SHO SIRS SL SLE SNAP SNM SNS s-NVH SOP SPC SpR SRE SSRI ssRNA STD STI SUI TAL TB TBW TC TCC tds TEAP TEDs TENS TESA TESE TET TGF TIN TIP TNF TNM TOT squamous cell carcinoma spinal cord injury serum creatinine standard error of the mean sex hormone binding globulin Sexual Health Inventory for Men senior house of \201 cer systemic in \202 ammatory response syndrome sublingual systemic lupus erythematosus synaptosomal a ssociated protein sacral nerve modulation sacral nerve stimulation symptomatic non-visible haematuria standard operating procedures suprapubic catheter specialist registrar skeletal- related events serotonin reuptake inhibitor single-stranded ribonucleic acid sexually trans mitted disease sexually transmitted infection stress urinary incontinence thick ascending l imb (of Loop of Henle) tuberculosis total body water testicular cancer transitional cell ca rcinoma ter die sumendus (to be taken 3 times per day) transurethral ethanol ablation of th e prostate thromboembolic deterrent stockings transcutaneous electrical nerve stimulation t esticular exploration and sperm aspiration testicular exploration and sperm extraction tuba l embryo transfer transforming growth factor testicular intratubular neoplasia (synonymous with IGCN) tubularized incised plate tumor necrosis factor tumor, node, metastasis transobt urator tape SYMBOLS AND ABBREVIATIONS xxxi TOV TPIF TRUS TS TSE TUIP TULIP trial of void transverse preputial island \202 ap transrectal ultrasonography tuberous sc lerosis testicular self-examination transurethral incision in the prostate transuretheral u ltrasound-guided laser-induced prostatectomy transurethal microwave thermotherapy transuret hal radiofrequency needle ablation transurethral resection transurethral resection of bladd er tumor transurethral resection of the ejaculatory ducts transurethral resection of prosta te transurethral resection syndrome transureteroureterostomy transurethral electrovaporizat ion of the prostate transurethral vaporization resection of the prostate total vaginal leng th tension-free vaginal tape tension-free vaginal tape obturator route trial without cathet er transition zone (international) unit urethral diverticulum undescended testis urea and e lectrolytes urinary incontinence United Kingdom ultra-low dose computed tomography ureterop elvic junction obstruction United States (of America) ultrasound scan urinary tract infecti on urge urinary incontinence unilateral ureteric obstruction upper urinary tract transition al cell carcinoma volt post-prostatic massage urine variant Creutzfeldt \200\223Jakob disea se voiding cystourethrography TUMT TUNA TUR TURBT TURED TURP TURS TUU TUVP TUVRP tvl TVT TVTO TWOC TZ U UD UDT U & E UI U K ULDCT UPJO USA USS UTI UUI UUO UUT-TCC V VB3 vCJD VCUG SYMBOLS AND ABBREVIATIONS xxxii VEGF VEGFR VH VHL VLAP VQ VRE vs VTE VUJ VUJO VUR VURD VVF W WBC WCC WHO wk WW XGP y YAG ZI FT vascular endothelial growth factor vascular endothelial growth factor receptor visible haem aturia von Hippel \200\223Lindau visual laser ablation of the prostate ventilation/perfusio n (scan) vancomycin-resistant enterococci versus venous thromboembolism vesicoureteric junc tion vesicoureteric junction obstruction vesicoureteric re \202 ux vesicoureteric re \202 ux with renal dysplasia vesicovaginal \201 stula watt white blood cell white cell count World Health Organization week watchful waiting xanthogranulomatous pyelonephritis year ytr ium-aluminum-garnet (laser) zygote intrafallopian transfer 1 Chapter 1 General principles of management of patients Communication skills 2 Documentation and note keeping 4 Patient safety in surgical practice 6 CHAPTER 1 General principles of management 2 Communication skills Communication is the imparting of knowledge and understanding. Good co mmunication is crucial for the surgeon in his or her daily interaction with patients. The n ature of any interaction between surgeon and patient will depend very much on the context o f the \200\230interview \200\231, whether you know the patient already, and on the quantit y and type of information that needs to be imparted. As a general rule, the basis of good c ommunication requires the following: \200 Give your name, explain who you are, greet the patient/relative appropri- ately (e.g. handshake), check you are talking to the correct per son. \200 Explain the purpose of the interview from the patient \200\231s perspective and yours and the desired outcome of the interview. \200 Establish the patient \200\231s bas eline knowledge and understanding. Use open questions, let the patient talk, and con \201 rm what they know. \200 Make it clear to the patient that they have your undivided attent ion \200\224that you are focusing on them. This involves appropriate body language (keep ey e contact \200\224don \200\231t look out of the window!). \200 The patient/relative may o ffer verbal or non-verbal indications about their thoughts or feelings. \200 What you thi nk should be the patient \200\231s main concerns may not be. Try to \201 nd out exactly w hat the patient is worried about. \200 Give information in small quantities and check tha t this has been under- stood. A good way of doing this is to ask the patient to explain wha t they think you have said. \200 Show empathy. Let the patient know you understand their feelings. \200 Don \200\231t express your personal views or beliefs. \200 Introduction. Establish the purpose of the interview. Listen actively. Pick up on and respond to cues. Elicit the patient \200\231s main concern(s). Chunks and checks. Be non-judgemental Alternate control of the interview between the patient and yourself. Allow the patient to take the lead where appropriate. \200 State clearly when you move on to a new subject. \200 Use terminology. Signpost changes in direction. Avoid the use of jargon. language the patient will understand, rather than medical COMMUNICATION SKILLS 3 Use body language that shows the patient that you are interested in their problem and that you understand what they are going through. Respect cultural differences; in some cultures, eye contact is regarded as a sign of aggression. \200 Summarize what you understand to b e the patient \200\231s problem and what the next steps are going to be. Body language. Summarize and indicate the next steps. CHAPTER 1 General principles of management 4 Documentation and note keeping The Royal College of Surgeons \200\231 guidelines state that each clinical history sheet should include the patient \200\231s name, date of birth, and record number. Each entry should be timed, dated, and signed, and your name and position (e .g. SHO for \200\230senior house of \201 cer \200\231 or SPR for \200\230specialist regi strar \200\231) should be clearly written in capital letters below each entry. You should a lso doc- ument which other medical staff were present with you on ward rounds or when seein g a patient (e.g. \200\230ward round \200\224SPR (Mr X)/SHO/HO \200\231). Contemporaneous note keeping is an important part of good clini- cal practice. Medical note s document the patient \200\231s problems, the inves- tigations they have undergone, the di agnosis, and the treatment and its outcome. The notes also provide a channel of communicati on between doctors and nurses on the ward and between different medical teams. In order for this communication to be effective and safe, medical notes must be clearly written. They w ill also be scrutinized in cases of complaint and litigation. Failure to keep accurate, mea ningful notes which are timed, dated, and signed, with your name written in capital letters below, exposes you to the potential for criticism in such cases. The standard of note keep - ing is seen as an indirect measure of the standard of care you have given your patients. Sloppy notes can be construed as evidence of sloppy care, quite apart from the fact that su ch notes do not allow you to provide evi- dence of your actions! Unfortunately, the defense of not having suf \201 cient time to write the notes is not an adequate one, and the cour ts will regard absence of documentation of your actions as indicating that you did not do w hat you said you did. Do not write anything that might later be construed as a personal com- ment about a patient or colleague (e.g. do not comment on an individual \200\231s character or manner). Do not make jokes in the patient \200\231s notes. Such comments are unlikely to be helpful and may cause you embarrassment in the future when you are asked to interpret them. Try to make the notes relevant to the situation so, e.g. in a patient with suspected bleedi ng, a record of blood pressure and pulse rate is important, but a record of a detailed neur ological history and examination is less relevant (unless, e.g. a neurological basis for th e patient \200\231s problem is suspected). The results of investigations should be clearly documented in the notes, preferably in red ink, with a note of the time and date when the investiga- tion was performed. Avoid the use of abbreviations. In particular, always write LEFT or RIGHT in capital letter s, rather than Lt/Rt or L/R. A handwritten L can sometimes be mistaken for an R and vise ve rsa. DOCUMENTATION AND NOTE KEEPING 5 Operation notes We include the following information on operation notes: \200 \200 \200 \200 \200 Patient name, number, and date of birth. Date of operation. Surgeon, assistants. Patient po sition (e.g. supine, prone, lithotomy, Lloyd \200\223Davies). Type of deep vein thrombosis (DVT) prophylaxis (AK \200\223TEDS, \202 owtrons, heparin, etc.). Type, time of administr ation, and doses of antibiotic prophylaxis. Presence of image intensi \201 er, if appropri ate. Type and size of endoscopes used. Your signature and your name in capitals. Post-opera tive instructions and follow-up, if appropriate. \200 \200 \200 \200 If a consultant is supervising you, but is not scrubbed, you must clearly state that the \200\230consultant (named) was in attendance \200\231. CHAPTER 1 General principles of management 6 Patient safety in surgical practice The aviation, nuclear, and petrochemical industries are termed \200\230high reli- ability organizations \200\231 (HROs) because they have adopted a variety of core safety principles that have enabled them to achieve safety success, desp ite \200\230operating \200\231 in high-risk environments. Surgeons can learn much from HRO s and can adopt some of these safety principles in surgical practice in order to improve sa fety in the non-technical aspects of care. Foremost amongst the safety principles of HROs are: Team working. Use of standard operating procedures (SOPs): carried out according to a set of rules and in a way that is standardiz ed across the organization. Cross-checking: or action has been done or administered by \200\230verbalizing \200\231 that action to another team member. This is most familiar when aircraft cabin crew are asked by the pilot to check that the doors of the plane are locked shut ( \200\230doors to cross-check \200\231) and crew members cross to the opposite door to con \201 rm this has been done. In surgical practice, an example of cross-checking coul d be \200\230antibiotic given? \200\231, con \201 rmed by a speci \201 c reply such as \200\230240mg IV gentamicin given \200\231. Regular audit and feedback of audit data: good and bad) are collected regularly and crucially, team members are noti \201 ed (e.g. in aud it meetings) of where they are performing well or badly. Establishment of variable hierarch ies: environment where junior staff are encouraged to \200\230speak up \200\231 if they be lieve an error is about to occur, without fear of criticism. Cyclical training: safe practi ce methods. \200 day-to-day tasks are members of the team check that a procedure, drug, performance data (both development of a working frequent and regular training sessions to reinforce 7 Chapter 2 Signi \201 cance and preliminary investigation of urological symptoms and signs Haematuria I: de \201 nition and types 8 Haematuria II: causes and investigation 10 Haemos permia 14 Lower urinary tract symptoms (LUTS) 16 Nocturia and nocturnal polyuria 18 Loin ( \202 ank) pain 20 Urinary incontinence 24 Genital symptoms 26 Abdominal examination in uro logical disease 28 Digital rectal examination (DRE) 30 Lumps in the groin 32 Lumps in the s crotum 34 CHAPTER 2 Signi \201 cance & preliminary investigation 8 Haematuria I: de \201 nition and types The presence of blood in the urine. The Joint Consensus Statement on the Initial Assessment of Haematuria (The Renal Associatio n and British Association of Urological Surgeons, July 2008) now terms macroscopic or gross haematuria as \200\230visible \200\231 haematuria (VH) \200\224the patient or doctor has seen blood in the urine or describes the urine as red or pink (or \200\230cola \200\231-co lored \200\224occasionally seen in acute glomerulonephritis). Microscopic or dipstick haematuria is \200\230non-visible \200\231 haematuria (NVH). Non-v isible haematuria is categorized as symptomatic (s-NVH, i.e. LUTS such as frequency, urgenc y, urethral pain on voiding, suprapu- bic pain) or asymptomatic (a-NVH). Non-visible haematuria (microscopic or dipstick haematuria). Blood is identi \201 ed by ur ine microscopy or by dipstick testing. Microscopic hae- maturia has been variably de \201 ned as 3 or more, 5 or more, or 10 or more red blood cells (RBCs) per high-power \201 eld . Samples sent from the com- munity by GPs to hospital labs have a signi \201 cant false n egative rate (due to red cell lysis in transit). The sensitivity of urine dipstick testing of a freshly voided urine sample is now good enou gh for detecting haematuria that routine con \201 rmatory microscopy is no longer consider ed necessary. Dipstick haematuria is con- sidered to be signi \201 cant if 1+ or more. \200\230Trace \200\231 haematuria is considered negative. No distinction is made between ha emolysed and non-haemo- lysed dipstick-positive urine; as long as 1+ or more of blood is de tected, it is considered signi \201 cant haematuria. Urine dipsticks test for haem (i.e. they test for the presence of haemo- globin and myoglob in in urine). Haem catalyzes oxidation of orthotolidine by an organic peroxidase, producing a blue-colored compound. Dipsticks are capable of detecting the presence of hemoglobin fro m one or two RBCs. \200 False-positive urine dipstick: bacterial peroxidases, povidone, hypochlorite. occurs in the presence of False-negative urine dipstick (rare): reducing agents (e.g. ascorbic acid \200 \224prevents the oxidation of orthotolidine). occurs in the presence of myoglobinuria, Is microscopic or dipstick haematuria abnormal? A few RBCs can be found in the urine of nor mal people. The upper limit of normal for RBC excretion is 1 million per 24h (as seen in he althy medi- cal students). In healthy male soldiers undergoing yearly urine examination ove r a 12y period, 40% had microscopic haematuria on at least one occasion, and 15% on two or more occasions. Transient microscopic haematuria may occur following rigorous exercise, sex ual intercourse, or from men- strual contamination. The fact that the presence of RBCs in the urine can be a perfectly normal \201 nding expl ains why in approximately 70% of \200\230patients \200\231 with microscopic or dipstick ha ematuria, no abnormality is found despite full conventional urological investigation (urine cytology, cystoscopy, renal ultrasonogra- phy, and intravenous urogram (IVU)).2 That said, a substantial proportion HAEMATURIA I: DEFINITION AND TYPES 9 with visible and a smaller, but signi \201 cant, proportion with NVH will have serious und erlying disease and since there is no way, other than by fur- ther investigation, of distin guishing the dipstick-positive patient without signi \201 cant disease from the dipstick-p ositive patient without signi \201 cant disease, the recommendation is to investigate all patients with dipstick haematuria. What is signi \201 cant haematuria? \200 \200 Any single episode of VH. Any single episode of s-NVH (in absence of urinary tract infectio n (UTI) or other transient causes). Persistent a-NVH \200\224de \201 ned as two out of thr ee dipsticks positive for NVH (in absence of UTI or other transient causes). Transient (non-signi \201 cant haematuria) is caused by: \200 UTI. Treat the UTI and repeat dipstick testing to con \201 rm the absence of haematuria. U TI is most easily excluded by a negative dipstick result for both leucocytes and nitrites. If dipstick haematuria positive with a negative dipstick result for both leucocytes and nit rites, investigate the haematuria further. Exercise-induced haematuria or rarely myoglobinu ria (VH and NVH). Repeat dipstick testing after a period of abstention from exercise. Menst ruation. Initial investigation for s-NVH and persistent a-NVH? \200 \200 \200 Exclude UTI or other transient causes. Plasma creatinine/eGFR. Measure proteinuria on a ran dom sample (24h urine collections for protein are rarely required).* Blood pressure (BP). When is urological referral warranted? \200 \200 \200 \200 All patients with VH. All patients with s-NVH. a-NVH in patients aged 40y or more. Persiste nt a-NVH (de \201 ned as two out of three positives for NVH). For the patient <40y with a-NVH, if eGFR is >60mL/min, BP <140/90, and no proteinuria (PCR <50mg/mmol or ACR <30mg/mmol), then while the a-NVH persists, it is recommended that the pa tient has an annual eGFR, BP check, and proteinuria check. If VH or s-NVH develops, referra l to urology for a cystoscopy and imaging is indicated. If eGFR is <60mL/min, BP >140/90, o r there is proteinuria (PCR >50mg/mmol or ACR >30mg/ mmol), nephrological referral is indic ated. Protein assessment on a single urine sample. Protein:creatinine ratio (PCR) or albumin:crea tinine ratio (ACR). Signi \201 cant proteinuria is a PCR >50mg/mmol or an ACR >30mg/mmol. 1 British Association of Urological Surgeons (2008) Haematuria guidelines [online]. Availab le from: M http://www.baus.org.uk/AboutBAUS/publications/haematuria-guidelines. 2 Khadra MH (2000) A prospective analysis of 1930 patients with hematuria to evaluate curre nt diagnostic practice. J Urol 163:524 \200\2237. CHAPTER 2 Signi \201 cance & preliminary investigation 10 Haematuria II: causes and investigation Urological and other causes of haematuria Non-visib le haematuria (microscopic or dipstick haematuria) is com- mon (20% of men >60y old). Bear in mind that most patients (70% \200\224and some studies say almost 90%)1,2 with NVH have n o urological pathology. Conversely, a signi \201 cant proportion of patients have glomerul ar disease despite having normal bp, a normal serum creatinine, and in the absence of prote inuria3,4 (although it is fair to say that most do not develop progressive renal disease an d those that do usually develop proteinuria and hypertension as impending signs of deterior ating renal function). The management algorithm for patients with negative urological haema turia investigations is shown on b p. 14. Causes of haematuria \200 Cancer: carcinoma (SCC)), kidney (adenocarcinoma), renal pelvis, and ureter (TCC), prostate . Stones: Infection: bacterial, mycobacterial (tuberculosis (TB)), parasitic (schistosomias is), infective urethritis. In \202 ammation: Trauma: pelvic fracture causing urethral rupt ure. Renal cystic disease benign prostatic hyperplasia (BPH, the Other urological causes: l arge, vascular prostate), loin pain haematuria syndrome, vascular malformations. Nephrologi cal causes of haematuria: oryoung adults and include, commonly, IgA nephropathy, post- infe ctious glomerulonephritis; less commonly, membrano-proliferative glomerulonephritis, Henoch \200\223Sch nlein purpura, vasculitis, Alport \200\231s syndrome, thin basement membrane disease, Fabry \200\231s disease, etc. Other \200\230medical \200\231 causes of haematuria : disorders \200\224congenital (e.g. hemophilia), anticoagulation therapy (e.g. warfarin), sickle cell trait or disease, renal papillary necrosis, vascular disease (e.g. emboli to th e kidney cause infarction and haematuria). Nephrological causes: children andyoung adults; proteinuria; RBC casts. bladder (transitional cell carcinoma (TCC), squamous cell \200 kidney, ureteric, bladder. \200 cyclophosphamide cystitis, interstitial cystitis. kidney, bladder, urethra (e.g. traumatic catheterization), \200 (e.g. medullary sponge kidney). tend to occur in children include coagulation more likely in the following situations \200\224 What percentage of patients with haematuria have urological cancers? \200 \200 Microscopic: Macroscopic: about 5 \200\22310%. about 20 \200\22325%.5 HAEMATURIA II: CAUSES AND INVESTIGATION 11 Urological investigation of haematuria \200\224VH, s-NVH, a-NVH aged >40y, persistent (2 ou t of 3 dipsticks) a-NVH Modern urological investigation involves urine culture (where, on t he basis of associated \200\230cystitis \200\231 symptoms, urinary infection is suspected) , urine cytology, cystoscopy, renal ultrasonography, and CT urography (CTU). Diagnostic cystoscopy Nowadays, this is carried out using a \202 exible, \201 bre optic cystoscope, unless radiological investigation demonstrates a bladder cancer, in which case one may forego the \202 exible cystoscopy and proceed immediately to rigid cystoscopy an d biopsy under anesthetic (transurethral resection of bladder tumor \200\224TURBT). What is the role of multidetector CT urography (MDCTU) in the investigation of haematuria? This is a rapid acquisition CT done following intravenous contrast admin- istration with hi gh spatial resolution. Overlapping thin sections can be \200\230reconstructed \200\231 int o images in multiple planes (multiplanar reformatting \200\224 MPR) so lesions can be image d in multiple planes. It has the advantage of a single investigation which potentially coul d obviate the need for the traditional \200\2304-test \200\231 approach to haematuria (IVU , renal ultrasound, \202 exible cystoscopy, urine cytology), although at the cost of a hi gher radiation dose (a 7- \201 lm IVU = 5 \200\22310mSV, 3-phase MDCTU = 20 \200\22325mSV) . There is evidence suggesting that MDCTU has reasonable sensitiv- ity and high speci \201 c ity for diagnosing bladder tumors6 (in patients with macroscopic haematuria 93% sensitivity , 99% speci \201 city) and that it has equivalent diagnostic accuracy to retrograde ureter o-pyelography (the retrograde administration of contrast via a catheter inserted in the low er ureter to outline the ureter and renal collecting system).7 Overall, for patients with h aematuria and no prior history of urological malignancy, for the detection of all urologica l tumors, it has approximately 65% sensitiv- ity and 98% speci \201 city8 \200\224so it on ly rarely calls a lesion a tumor when, in fact, the lesion is benign, but it still fails to diagnose a signi \201 cant propor- tion of urinary neoplasms (sensitivity for upper tract neoplasms 80%, for bladder tumors 60%). The role of MDCTU (described by some as the \200\230ultimate \200\231 imaging modal- ity) in the investigation of haematuria remains controversial. MDCTU in all patients with haemat uria (microscopic, macroscopic), when most will have no identi \201 able cause for the hae maturia, has a cost (high radiation dose, \201 nancial). A targeted approach, aimed at th ose with risk factors for urothelial malignancy (age >40y, macroscopic as opposed to micro- scopic haematuria, smoking history, occupational exposure to benzenes and aromatic amines) , might be a better use of this resource, rather than using MDCTU as the \201 rst imaging test for both high- and low-risk patients. Thus, the \200\230best \200\231 imaging probab ly depends on the context of the patient. CHAPTER 2 Signi \201 cance & preliminary investigation 12 Should cystoscopy be performed in patients with a-NVH? The American Urological Association (AUA) \200\231s Best Practice Policy on Asymptomatic Microscopic Hematuria1 (in the process of being revised at the time this 3rd edition went to press) recommends cystoscopy in all high-risk patients (high risk for development of TCC) with microscopic haematuria (the AUA still uses the term \200\230microscopic \200\231 haematuria) (see risk factors b pp. 12 \200\22313).9 \200 Patients at high risk for TCC: exposure to chemicals or dyes (benzenes or aromatic amines), analgesic abuse (phenacetin), history of pelvic irradiation, previous cyclophosphamide tre atment. positive smoking history, occupational In asymptomatic, low-risk patients <40y, it states that \200\230it may be appro- priate to defer cystoscopy \200\231, but if this is done, urine should be sent for cytology. However , the AUA also states that \200\230the decision as to when to proceed with cystoscopy in l ow-risk patients with persistent microscopic haematuria must be made on an individual basis after a careful discussion between the patient and physician \200\231. It is our policy to inform such patients that the likelihood of \201 nding a bladder cancer is low, but neve rtheless we recommend \202 exible cystoscopy. The patient then makes a decision as to whe ther or not to proceed with cystoscopy based on their interpretation of \200\230low risk \200\231. If no cause for haematuria (VH or NVH) is found with cystoscopy and CT urography, is furthe r investigation necessary? Some say yes, quoting studies that show serious disease can be i denti \201 ed in a small number of patients where, in addition, retrograde ureterogra- phy , endoscopic examination of the ureters, and renal pelvis (ureteros- copy) and renal angiog raphy were done. Others say no, citing the absence of development of overt urological cance r during 2 \200\2234y follow-up in patients originally presenting with microscopic or macro scopic haematuria (although without further investigations).10 For patients with negative initial investigations, the AUA \200\231s Best Practice Policy o n Asymptomatic Microscopic Hematuria9 advises repeat urinalysis, urine cytology, and BP mea surement at 6, 12, 24, and 36 months, with repeat imaging and cystoscopy where dipstick or microscopic haematu- ria persists (in the process of being revised at the time of this 3rd edi- tion went to press). The diagnostic yield from repeat testing where initial tests are normal remains to be identi \201 ed with certainty. There is evidence that unless a patien t represents with visible haematuria, repeat urologic investigation in those with persisten t dipstick or microscopic haematuria will not identify any additional signi \201 cant urol ogic pathology and neph- rological investigation only in a very small number of patients wi th IgA nephropathy.11 The EAU currently has no policy for the management or follow-up of patients with persistent dipstick or microscopic haematuria. HAEMATURIA II: CAUSES AND INVESTIGATION 13 If no cause for NVH is found, is there a risk of subsequent urological cancer developing (i .e. do normal initial haematuria investigations fail to identify urologic cancer in some pa tients)? Over 10 \200\22313y of follow-up, two studies have revealed that where initial inv estigations in those patients with asymptomatic dipstick haematuria are negative and repeat dipstick analysis after full urologic investigation reveals no haematuria, no patient deve loped urological cancer.11,12 If NVH persists after initial negative investigation, should the patient undergo repeat inv estigation? Where dipstick haematuria persists after initial renal imaging and cystos- copy reveal no cause, the diagnostic yield of repeat investigation is very low. Nephrologic and repeat urological investigation reveal no urological malignancies, IgA nephropathy in 12%, and UTI in 24%.11 The recommendation from these studies is that repeat urological inves- tigation is not nece ssary unless a patient become symptomatic or develops visible haematuria. References 1 Edwards TJ, Dickinson AJ, Natale S, et al. (2006) A prospective analysis of th e diagnostic yield resulting from the attendance of 4020 patients at a protocol-driven haem aturia clinic. BJU Int 97:301 \200\2235. 2 Sultana SR, Goodman CM, Byrne DJ, Baxby K (1996) Microscopic haematuria: urological investigation using a standard protocol. Br J Urol 78:691 \200\2238. 3 Topham PS, Harper SJ, Furness PN, et al. (1994) Glomerular disease as a cause of isolated microscopic haematuria. Q J Med 87:329 \200\22335. 4 Tomson C, Porter T (2002) Asymptomatic microscopic or dipstick haematuria on adults: whic h investigations for which patients? A review of the evidence. Br J Urol 90:185 \200\22398. 5 Khadra MH, Pickard RS, Charlton M et al. (2000) A prospective analysis of 1930 patients w ith hematuria to evaluate current diagnostic practice. J Urol 163:524 \200\2237. 6 Turney BW, Willatt JM, Nixon D, et al. (2006) Computed tomography urography for diagnosing bladder cancer. BJU Int 98:345 \200\2238. 7 Cowan NC, Turney BW, Taylor NJ, et al. (2007) Multidetector computed tomography urography for diagnosing upper urinary tract urothelial tumors. BJU Int 99:1363-70. 8 Sudakoff GS, D unn DP, Guralnick ML, et al. (2008) Multidetector computed tomography urography as the primary imaging modality for detecting urinary tract neoplasms in patients with asymptomatic hematuria. J Urol 179:862 \200\2237. 9 Grossfeld GD (2001) Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association Best Practice Policy-Part II: patient evaluation, cytology, voided markers, imaging, cystoscopy, nephrology evaluation and follow-up. Urology 57:604 \200\22310. 10 Khadra MH (2000) A prospective analysis of 1930 patients with hematuria to e valuate current diagnostic practice. J Urol 163:524 \200\2237. 11 Mishriki SF (2008) Diagnosis of urologic malignancies in patients with asymptomatic dips tick haematuria: prospective study with 13year \200\231s follow-up. Urology 71:13-163. 12 Howard RS (1991) Long-term follow-up of asymptomatic microhematuria. J Urol 145:335 \200 \2236. CHAPTER 2 Signi \201 cance & preliminary investigation 14 Haemospermia De \201 nition The presence of blood in the semen. Usually intermittent, benign, self-limi ting, and no cause identi \201 ed. Causes Age <40y: usually in \202 ammatory (e.g. prostatitis, epididymo-orchitis, ure- thri tis); infective, including sexually transmitted diseases (STDs) (e.g. gonococcus), non-STD infection (e.g. Enterococcus faecalis, Chlamydia tra- chomatis, Ureaplasma urealyticum), or viral infection (e.g. Herpes simplex), urethral warts or idiopathic (though to an extent, this re \202 ects the limited investigation that is usually carried out in this age group) . Rarely, testicular tumor; perineal or testicular trauma. Tumors are found in 2.4%. Age >40y: as for men aged <40 \200\224commonest cause is now post-transrec- tal ultrasound (TRUS) biopsy of prostate; prostate cancer; bladder cancer; testicular cancer; BPH; dilated veins in the prostatic urethra; prostatic or seminal vesicle calculi; hypertension; carcin oma of the seminal vesicles; post-external beam radiotherapy or brachytherapy for prostate cancer. Tumors are found in 3.5% (mostly prostatic, rarely testis, seminal vesicle, epididy mal). Rare causes at any age: bleeding diathesis (von Willebrand \200\231s disease, hemophilia, a cquired coagulation defects); utricular, M llerian or seminal vesicle cysts \200\224which may cause ductal obstruction, dilatation, distension, and rupture of blood vessels; TB; sch istosomiasis; amyloid of prostate or seminal vesicles; post-injection of hemorrhoids. Very rarely, haemosper- mia may be confused with melanospermia from urinary tract melanoma. NB. Abnormalities detected on TRUS or MRI may not necessarily be the cause of the haemospermia. Examination Examine the testes, epididymis, prostate, and seminal vesicles (DRE). Measure B P. Investigation Send urine for culture. If risk of exposure to STDs, refer to local STD clini c for STD screen. If the haemospermia resolves after a single episode, an argument can be m ade for doing nothing else. If it recurs or persists, then even in young men (2.4% risk of \201 nding cancer if <40y old), arrange tests for PSA, FBC, LFTs and clotting, TRUS, \202 exible cystoscopy (look for ure- thral polyps, urethritis, prostatic cysts, urethral f oreign bodies, stones, and vascular abnormalities) and renal ultrasound, pelvic MRI (MRI an giography can identify rare vascular abnormalities). The author has a low threshold for \202 exible cystoscopy given the simplicity of doing this test. If haematuria coexists, inv estigate this as described. HAEMOSPERMIA 15 Treatment This is directed at the underlying abnormality, if found. If no cause is found, r eassure the patient that most cases are self-limiting. Further reading Ganabathi K, Chadwick D, Feneley RCL, Gingell JC (1992) Haemospermia. Br J Urol 69:225 \200\22330. Jones DJ (1991) Haemospermia: a prospective study. Br J Urol 67:88 \200\22390. Ahmad I, Krishna NS (2007) Hemospermia. J Urol 177:1613 \200\2238 CHAPTER 2 Signi \201 cance & preliminary investigation 16 Lower urinary tract symptoms (LUTS) A plethora of terms have been coined to describe the sy mptom complex traditionally associated with prostatic obstruction due to BPH. The \200\230 clas- sic \200\231 prostatic symptoms of hesitancy, poor \202 ow, frequency, urgency, noc turia, and terminal dribbling have, in the past, been termed \200\230pros- tatism \200\231 or simply \200\230BPH symptoms \200\231. One sometimes hears these symp- toms being descr ibed as due to \200\230BPO \200\231 (benign prostatic obstruction) or benign prostatic enl argement ( \200\230BPE \200\231; benign prostatic enlargement) or, more recently, \200\230 LUTS/BPH \200\231. However, these \200\230classic \200\231 symptoms of pro- static disease bear little relationship to prostate size, urinary \202 ow rate, residual urine volume o r indeed, urodynamic evidence of bladder outlet obstruction.1,2 Furthermore, age-matched me n and women have similar \200\230prostate \200\231 symptom scores,3,4 but women obviously have no prostate. We, therefore, no longer use the expression \200\230prostatism \200\231 to describe the symp- tom complex of hesitancy, poor \202 ow, etc. Instead, we call such symp- toms \200\230lower urinary tract symptoms \200\231 (LUTS), which is purely a descrip tive term avoiding any implication about the possible underlying cause of these symptoms.5 The new terminology \200\230LUTS \200\231 is useful because it reminds the urolo- gist to consider possible alternative causes of symptoms which may have absolutely nothing to do wi th prostatic obstruction and it reminds us to avoid operating on an organ, such as the pros tate, when the cause of the symptoms may lie elsewhere. Baseline symptoms can be \200\230measured \200\231 using a symptom index. The most widely used is the International Prostate Symptom Score (IPSS) which, in addition to the seven sym ptoms of the American Urological Association- Symptom Index (AUA-SI), includes a question f or the patient to assess the \200\230bothersomeness \200\231 of their LUTS6, the AUA-SI.