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    This document contains an introduction and acknowledgements for a urology case study workbook. The introduction provides background on the author's experience in urology and role in developing the case studies. It expresses hope that the workbook will be a useful educational tool. The acknowledgements section thanks the individual authors of the case studies and organizations that supported the project. The workbook contains multiple urology case studies, including ones on urinary tract infection, lower urinary tract symptoms, haematuria, scrotal swellings, and female incontinence. The first case asks how to proceed with a patient presenting with symptoms of a urinary tract infection, including instructing a midstream urine collection and

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    This document contains an introduction and acknowledgements for a urology case study workbook. The introduction provides background on the author's experience in urology and role in developing the case studies. It expresses hope that the workbook will be a useful educational tool. The acknowledgements section thanks the individual authors of the case studies and organizations that supported the project. The workbook contains multiple urology case studies, including ones on urinary tract infection, lower urinary tract symptoms, haematuria, scrotal swellings, and female incontinence. The first case asks how to proceed with a patient presenting with symptoms of a urinary tract infection, including instructing a midstream urine collection and

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    3 views14 pages

    Urology Case Study Workbook - : Questions

    Uploaded by

    Edyedu
    This document contains an introduction and acknowledgements for a urology case study workbook. The introduction provides background on the author's experience in urology and role in developing the case studies. It expresses hope that the workbook will be a useful educational tool. The acknowledgements section thanks the individual authors of the case studies and organizations that supported the project. The workbook contains multiple urology case studies, including ones on urinary tract infection, lower urinary tract symptoms, haematuria, scrotal swellings, and female incontinence. The first case asks how to proceed with a patient presenting with symptoms of a urinary tract infection, including instructing a midstream urine collection and

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    © All Rights Reserved
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    of 14

    UTIs

    Urology Case Study

    LUTS
    Workbook - Questions

    Haematuria
    Developed in Partnership with
    the CME tutors for the CME
    Network

    Scrotal Swellings
    Female Incontinence

    Facilitated by an educational grant by GlaxoSmithKline


    Date of Preparation. September 5th 2011

    IE/DUTT/0025/11
    UTIs
    LUTS
    Foreword

    Working as a urologist across both St. James’s & Tallaght Hospitals for 22

    Haematuria
    years I have garnered unique insights not only into the treatment pathways
    for patients with urinary problems but also into the comfortable level of
    general practitioners in managing these conditions in the community. I
    believe that as secondary care physicians it is our role to support GPs, as
    best we can, to the appropriate management of urology conditions. One of
    the most effective educational tools, in my experience, is learning by case
    study discussion.

    I was therefore very keen to be involved with the CME Network in the
    development of the enclosed Urology Case Study Workbook and I want

    Scrotal Swellings
    to pay tribute to the other contributors who are acknowledged on the
    following pages.

    I sincerely hope this workbook proves to be a useful learning and reference


    tool and I wish you every success in your practices.

    Best wishes,

    Mr. Ronald Grainger. MB FRCSI D.CH

    Female Incontinence
    Consultant Urologist at Adelaide Meath Hospital Tallaght
    and St. James’s Hospital Dublin 8.
    President Irish Society of Urology 2010 - 2012
    UTIs
    Acknowledgements Case Study 1:
    Urinary Tract Infection

    LUTS
    Authors of the individual Case Studies: A 33 year old lady attends your practice with a 2 day history of increased frequency of
    micturition, dysuria and low back pain. She has noticed a foul smell from her urine. Of
    note is her third attendance at your office with similar symptoms in the past 6 months.
    Urinary Tract infection Mr. Ivor Cullen

    Haematuria
    Male Urinary Tract Symptoms Mr. Ronan Long
    Q. How do you proceed?
    Haematuria Mr. Arun Thomas

    Scrotal Swellings (1 & 2) Mr. Ron Grainger ....................................................................................................................................................

    Female Incontinence Mr. Ron Grainger ....................................................................................................................................................

    ....................................................................................................................................................

    Special thanks to Dr. Annraoi Finnegan, Direcrtor of CME and Dr. Illona Duffy, CME tutor ....................................................................................................................................................
    & GP for their support in reviewing these case studies.

    Scrotal Swellings
    ....................................................................................................................................................

    Q. How do you instruct your patient to collect an MSU?

    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................

    Female Incontinence
    ....................................................................................................................................................

    Q. What organisms are likely to be implicated in a community


    acquired UTI?

    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................
    Copyright Notification:
    Copyright belongs to the individual author of each case study. Therefore no case study ....................................................................................................................................................
    can be altered or taken out of context without the expressed, written consent of the
    individual author. ....................................................................................................................................................
    UTIs
    Q. How should you treat your patient at presentation in your Summary notes
    surgery?

    ....................................................................................................................................................

    LUTS
    .................................................................................................................................................... ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................

    Haematuria
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................
    Q. What advice might you give to your patient for the future?
    ....................................................................................................................................................

    Scrotal Swellings
    .................................................................................................................................................... ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................

    Female Incontinence
    Q. When should you refer for further assessment by a Specialist?
    ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    ....................................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................
    UTIs
    Case Study 2: Q. What is the significance of recent onset of nocturnal enuresis in an
    individual with LUTs?
    Male Urinary Tract Symptoms ....................................................................................................................................................

    LUTS
    ....................................................................................................................................................
    A 61year old male presents with difficulty with urination over the previous 6 months.
    He is particularly bothered as he has to pass urine twice per night and also complains of ....................................................................................................................................................
    hesitancy, slow stream and post micturition dribbling. He has no previous urological his-
    tory or neurological symptoms. ....................................................................................................................................................

    Haematuria
    ....................................................................................................................................................
    Q. How can you assess the severity of his symptoms objectively?

    ....................................................................................................................................................
    Q. Is it necessary for a GP to do a rectal examination
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................

    Scrotal Swellings
    ....................................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................
    Q. What is the most common condition in ageing men presenting
    with LUTS and what are the typical symptoms.

    Q. Would you routinely send blood for PSA testing:


    ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    Female Incontinence
    .................................................................................................................................................... ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    ....................................................................................................................................................
    Q. What other symptoms may be present secondary to obstruction.

    .................................................................................................................................................... Q. How would you advise this patient given that his DRE and PSA are
    normal.
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................
    UTIs
    Q. Would you commence treatment for this man? Case Study 3: Haematuria
    .................................................................................................................................................... A 56 year old man presents to your surgery with new onset lower urinary tract symptoms

    LUTS
    (LUTS) over the past month. He has noticed increased frequency of micturition at 2
    .................................................................................................................................................... hourly intervals and nocturia two occasions each night. He reports a good flow with no
    other symptoms suggestive of obstruction. He has not had any visible haematuria but
    .................................................................................................................................................... has noticed that his urine has been dark in colour on occasion.

    ....................................................................................................................................................

    Haematuria
    Q. What may be important in his past history and why?
    ....................................................................................................................................................

    ....................................................................................................................................................
    Q. Which treatment for which patient.
    ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    Scrotal Swellings
    .................................................................................................................................................... ....................................................................................................................................................

    ....................................................................................................................................................

    .................................................................................................................................................... Q. He gives a history of a 15 year pack history of smoking which


    he stopped 7 years ago. Physical examination including rectal
    Q. When should a patient with BPE be referred to a Urologist? examination, blood pressure etc is normal. What investigations
    would you order for this man?
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................

    Female Incontinence
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    .....................................................................................................................................................
    UTIs
    Q. One week later he returns for the results of his tests which show
    Hb 11.8 wcc 7.4 Urine microscopy shows 10-50 red cells with no
    Case Studies 4 to 6:
    white cells and no growth. What do you do now? Scrotal Swellings

    LUTS
    ....................................................................................................................................................

    .................................................................................................................................................... Case Study 4:


    .................................................................................................................................................... A 22 year old man comes to see you with a 2 month history of left testicular pain and

    Haematuria
    swelling.
    ....................................................................................................................................................
    On examination: The left testis is normal. There is a 2 cm swelling just above the testis.

    Q. What terminology are you aware of for haematuria? Q. When presented with a scrotal swelling what is the first thing
    you must confirm?
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................

    Scrotal Swellings
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................
    Q. What is significant haematuria?

    .................................................................................................................................................... Q. What may help you confirm the diagnosis.


    ....................................................................................................................................................

    Female Incontinence
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................

    Q. When should referral to urologist be sought? ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................
    UTIs
    The swelling does transilluminate and appears cystic. Q. If the patient enquired if this was a malignant or pre malignant
    Q. What is the likely diagnosis? condition how would you answer?

    ....................................................................................................................................................

    LUTS
    ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    Haematuria
    .................................................................................................................................................... ....................................................................................................................................................

    Q. If you are concerned that this is a testis tumour what should your
    management be?
    Q. How might you manage this?
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................

    Scrotal Swellings
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................

    Q. What would lead you more to a diagnosis of epididymitis rather


    Q. If the pain did not settle how would you manage it? than tumour?

    ....................................................................................................................................................

    Female Incontinence
    ....................................................................................................................................................
    .................................................................................................................................................... ....................................................................................................................................................
    .................................................................................................................................................... ....................................................................................................................................................
    .................................................................................................................................................... ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    UTIs
    Q. What is the treatment for acute epididymitis?
    Case Study 5:
    .................................................................................................................................................... A 22 year old man presents with a similar history. On examination there is diffuse
    swelling in the left hemiscrotum.

    LUTS
    ....................................................................................................................................................

    .................................................................................................................................................... Q. How would you go about making a diagnosis?


    ....................................................................................................................................................
    ....................................................................................................................................................

    Haematuria
    ....................................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................
    Q. Which would be the most appropriate antibiotic?
    ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    ....................................................................................................................................................

    Scrotal Swellings
    .................................................................................................................................................... Q. If you are certain this is a cystic swelling what is the likely
    ....................................................................................................................................................
    diagnosis?

    ....................................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................

    Q. If the symptoms did not settle over a 72 hour period what other ....................................................................................................................................................
    antibiotic might you employ and why?
    ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    Female Incontinence
    ....................................................................................................................................................

    .................................................................................................................................................... Q If it is a hydrocele what investigation might you order and why?


    ....................................................................................................................................................
    ....................................................................................................................................................
    ..............................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................
    UTIs
    Q. If the swelling is solid not cystic what is your differential
    diagnosis?
    Case Study 6:
    A 30 year old man presents with a dull ache and heaviness in his left scrotum and a
    probable swelling. He and his partner have been trying to conceive unsuccessfully for 18
    ....................................................................................................................................................

    LUTS
    months.
    ....................................................................................................................................................

    ....................................................................................................................................................
    Q. What is your differential diagnosis?
    ....................................................................................................................................................

    Haematuria
    .................................................................................................................................................... ....................................................................................................................................................

    ....................................................................................................................................................

    Q. If the ultrasound showed that this was an uncomplicated ....................................................................................................................................................


    hydrocele how would you advise the patient? ....................................................................................................................................................

    ....................................................................................................................................................
    ....................................................................................................................................................

    Scrotal Swellings
    ....................................................................................................................................................

    ....................................................................................................................................................
    Q. How would you demonstrate a varicocele?

    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................

    Female Incontinence
    ....................................................................................................................................................

    Q. What effect can a varicocele have in fertility potential?

    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................
    UTIs
    Q. The patient states that he and his partner are keen to achieve a
    pregnancy what would you do next?
    Case Studies 7: Female Incontinence
    .................................................................................................................................................... SCENARIO a

    LUTS
    .................................................................................................................................................... A 44 yr old woman presents with a 3 year history of worsening urinary incontinence.
    She wears 3 large incontinence pads per day.
    ....................................................................................................................................................

    .................................................................................................................................................... Q. What is the definition of urinary incontinence?

    Haematuria
    ....................................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................

    Q. The semen analysis findings are those of OAT syndrome. How ....................................................................................................................................................
    would you manage this patient?
    ....................................................................................................................................................

    Scrotal Swellings
    .................................................................................................................................................... ....................................................................................................................................................

    .................................................................................................................................................... Q. What sub types of urinary incontinence are there?


    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................

    Q. What treatment may be necessary? ....................................................................................................................................................

    Female Incontinence
    Q. What is the definition of Stress Urinary Incontinence?
    ....................................................................................................................................................

    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................

    ....................................................................................................................................................
    UTIs
    Q. What is the definition of Urge (Urgency) Incontinence? Q. What do you think is the primary diagnosis?

    .................................................................................................................................................... ....................................................................................................................................................

    LUTS
    .................................................................................................................................................... ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    Haematuria
    .................................................................................................................................................... ....................................................................................................................................................

    Q. In light of the preceding definitions, what specific questions will Q. What would you do next?
    you ask this woman which may be relevant to her incontinence?
    ....................................................................................................................................................
    .................................................................................................................................................... ....................................................................................................................................................

    Scrotal Swellings
    .................................................................................................................................................... ....................................................................................................................................................
    .................................................................................................................................................... ....................................................................................................................................................
    .................................................................................................................................................... ....................................................................................................................................................
    ....................................................................................................................................................

    Q. If physiotherapy failed to improve things, what else might you


    consider?
    SCENARIO b
    ....................................................................................................................................................
    She admits to leaking on coughing, sneezing, walking quickly and occasionally during

    Female Incontinence
    sexual intercourse. She does however also admit that occasionally she has a compelling ....................................................................................................................................................
    desire to micturate but is unable to make it to the toilet before leaking.
    ....................................................................................................................................................

    Q. How would you proceed from here? ....................................................................................................................................................

    ....................................................................................................................................................
    Q. If conservative measures fail to improve the patient’s symptoms,
    .................................................................................................................................................... what would you do next?
    .................................................................................................................................................... ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    .................................................................................................................................................... ....................................................................................................................................................

    ....................................................................................................................................................
    UTIs
    SCENARIO c
    Despite the fact that the woman’s history suggested predominantly stress urinary
    incontinence, her urodynamics tracing showed a very overactive bladder.

    LUTS
    Q. What is the treatment of overactive bladder?
    ....................................................................................................................................................

    Haematuria
    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................

    Q. What are common side effects of anti cholinergic treatment?


    ....................................................................................................................................................

    Scrotal Swellings
    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................

    Q. In which underlying condition are anti cholinergic agents contra


    indicated?
    ....................................................................................................................................................

    Female Incontinence
    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................

    Q. If oral anticholinergic treatment fails, what other medical


    treatment is available?

    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................

    ....................................................................................................................................................
    IE/BPH/0001/10

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