18/02/2015

Question 0

What are the NICE guidelines for the treatment of a single UTI in a man?

Answer 0

Nice guidelines recommend for single UTI in a man:
Trimethoprim 200mg bd 7 days
Or Nitrofurantoin 50 mg 4 times daily for 7 days or 100mg slow release bd for 7 days.
Arrange follow up eg after 48 hours to check response to treatment and also urine culture results to make sure that the bacteria are sensitive to the abx that has been prescribed
If symptoms have improved by second follow up, continue with current abx
If symptoms persist after abx treatment, consider whether referral to urology is needed

Question 1

Patient comes into the GP surgery complaining of haematuria, which they have recently noticed. What are the first steps?

Answer 1

Find out whether they have a fever, pain on urination, increased frequency. If they do, your top differential will be UTI, so treat for this. If they have no other UTI like symptoms, dipstick the urine anyway to check for UTI.
In some cases, you may also need to exclude exercise induced haematuria, myoglobinuria, menstruation.

All children with haematuria need to be referred

Question 2

What are the NICE guidelines for the treatment of recurrent UTI in a man?

Answer 2

If recurrent UTI eg 2 or more episodes in a 3 month period:
Treat each episode and get a urine culture each time
Consider alternative diagnoses such as urethritis
Refer to urology
Advise to drink 2l of fluid per day

Question 3

Question 4

What is “significant haematuria”

Answer 3

Significant haematuria is:
Any one episode of visible haematuria
Any one episode of Symptomatic non visible haematuria (voiding symptoms: hesitancy, frequency, urgency, dysuria) in the absence of UTI or other infection
Persistent asymptomatic non-visible haematuria in the absence of UTI or other infection

Question 4

If a patient has significant haematuria and UTI, over-exercise and menstruation have all been ruled out, what do you think about then?

Answer 4

Other causes of haematuria:
Stones in the renal pelvis or ureter
Urethritis
BPH (due to inflammation of the prostate and urethra?)
Cystitis
Transitional carcinoma of the bladder
Prostate cancer
Trauma due to accident or catheter
Inflammation: glomerulonephritis, henoch-schonlein, igA nephropathy, goodpastures, polyarteritis nodosa, post irradiation.
Stones, cysts, polycystic kidneys, congenital vascular abnormalities
Toxins: NSAIDS

Other causes of red/dark urine
Haemoglobinuria: dipstick positive, but no cells
Myoglobinurea
Food. Eg beetroot
Rifampicin, nitrofurantoin, senna
Porphyria
Bilirubinuria

Question 5

How do you start investigating for the causes of haematuria other than UTI?

Answer 5

How to start investigating for other causes:
Exclude UTI and other transient causes
Plasma creatinine and eGFR
Measure proteinuria: send urine for protein:creatinine ratio
Measure the BP

Other initial investigations may include:
FBC for anaemia and clotting screen
Urine red cell morphology: dysmorphic erythrocytes suggests a renal origin
Cytological exam of the urine