DR JOSH CULLIMORE GP CLINICAL LEAD UROLOGY Visible haematuria DR JOSH CULLIMORE GP CLINICAL LEAD UROLOGY

clarify that the blood is coming from the urethra rather than from the rectum or vagina. Urine discoloration may result from other causes, including beetroot (more rarely myoglobinuria, haemoglobinuria or drugs such as rifampicin, nitrofurantoin and doxorubicin) Other relevant aspects of the history include smoking status, any past urological problems, occupational history and whether the patient is on antiplatelet or anticoagulant therapy. all cases of VH are significant and require further investigation, including patients taking warfarin or antiplatelet therapy. It is important to enquire whether there are any associated symptoms such as dysuria, frequency, lower urinary tract symptoms, loin pain or whether the haematuria is painless (a red flag symptom).

Significant haematuria is considered to be 1+ or more on dipstick and trace haematuria should be regarded as negative. If haematuria is identified on dipstick, routine laboratory confirmation is not necessary. after treatment (ideally seven days after completing antibiotics), dip urine again to confirm that the haematuria has completely resolved. REFER Urgently if haematuria still present.

Non-visible haematuria Dr josh cullimore Gp urology clinical lead

Causes of non-visible haematuria include: transient urinary tract infections exercise related spurious menstrual contamination sexual intercourse foods such as beetroot, blackberries and rhubarb rhabdomyolysis drugs - doxorubicin, cholorquine, rifampicin chronic lead or mercury poisoning (2)

Urological Benign prostatic hypertrophy Stones (8% of those with persistent microscopic haematuria) Cancer (5%) (bladder, kidney, prostate, ureter) Cystitis/pyelonephritis Prostatitis or urethritis Schistosomiasis rarer: Radiation cystitis, Urethral strictures, TB, Medullary sponge kidney, Cyclophosphamide-induced, AV, Renal artery thrombosis, Polycystic kidney, Papillary necrosis of any cause, Loin pain haematuria syndrome.

Nephrological Ig A nephropathy (Berger's disease) Thin basement membrane disease. Rarer: Acute glomerular diseases (some forms of glomerulonephritis, lupus, vasculitis, Goodpasture's disease, HSP, haemolytic uraemic syndrome), Chronic primary glomerular disease (some forms of glomerulonephritis, membranous nephropathy), Familial causes (polycystic kidney disease, Alport's syndrome, Fabry's disease, nail– patella syndrome).

PSA & Suspected Prostate Cancer Jhumur Pati Consultant Urological Surgeon

BAUS Age Specific Normal PSA Values 40-49 2.7 50-59 3.9 60-69 5 70-79 7.2 80-84 10 85+ 20

Causes of Raised PSA Urinary infection Prostatitis Benign prostatic hypertrophy Urinary retention Vigorous cycling Ejaculation Prostate stimulation (cystoscopy, biopsy, DRE, anal intercourse).

Prostate Cancer Risk Factors  Age : Prostate cancer mainly affects men over 50, and risk increases with age. The average age of diagnosis is between 70 and 74 years  Family history : Father or brother had prostate cancer, risk increases 2.5 fold; risk increases further if father or brother were less than 60 years old when diagnosed. Increased risk if mother or sister has had breast cancer, particularly less than 60 years old or BRCA1/2 carriers  Ethnicity: Afro-Caribbean men have an increased risk; 1 in 4 Afro- Caribbean men will have prostate cancer in their lifetime.

When To do a PSA Tests ? All patients should have a history, examination and counselling :  LUTS : nocturia, frequency, hesitancy, urgency  Erectile dysfunction  Visible haematuria  Family History

What the Patient Should Expect The patient is on a suspected cancer pathway : 1st Appt : History, Examination, Discussion Day 1-7 2nd Appt: MRI (CT/Bone) Scan Day 8-10 3rd Appt : TRUS Biopsy Day 15 MDT Meeting Discussion Day 30 4th Appt : Results After MDT Day 30-32 5th Appt : External Referral Day 33-35

Patients with Prostate Cancer Patient attends an MDT Clinic: Diagnosis & Staging Treatment Options Treatment may be commenced Referral where appropriate Key Worker is allocated e-HNA planned Follow-up planned

JHUMUR PATI CONSULTANT UROLOGICAL SURGEON LUTS in MEN JHUMUR PATI CONSULTANT UROLOGICAL SURGEON

Initial Consultation History of Complaint (IPSS) PMH DH FH Examination (General, Abdo, DRE, genitals, ankles) Urine Dip Test U/Es (PSA after counselling if appropriate) KUB US

BPH Nocturia Polydipsia High caffeine intake Diabetes Mellitus Diabetes Insipidus CCF CVA/Head Injury BPH

Management of LUTS Mild (IPSS <7) : Life Style changes to improve QoL Mod (IPSS 8-19): Tamsulosin (+ Finasteride, + anticholinergic) Severe (IPSS 20-35): Refer to secondary care

When to Refer ? Refractory to medical therapy Unable to tolerate medical therapy Recurrent UTIs/orchitis Abnormal USS –calculus, thickened wall Increasing residual urine volumes on USS Hydronephrosis Acute Urinary retention (A&E)

What happens next ? Changes to therapy Tests – FR & BS, UDS, cystoscopy Counsel regarding surgery Surgery : BNI, TURP Offer CISC or long-term catheter

Thank You !

Prostate cancer stratified follow up of stable prostate cancer patients in primary care Background National Cancer Survivorhip Initiative 2012 recommended stratified follow up for low risk patients in breast/colorectal/prostate NICE Prostate Cancer CG 175 2014 recommends that patients undergoing “watchful waiting” and those stable 2 years after radical treatment should be offered follow up outside of secondary care TCST and PCUK developed a primary care led follow up model, piloted in Croydon CCG Now being rolled out across London, with exception of NEL/Bartshealth patch, which is using secondary care led follow up at present

Aims: Release some secondary care capacity Improve patient experience through care closer to home and extended cancer care reviews for prostate cancer

Secondary care (Homerton) will identify patients suitable for transfer to primary care-led follow up GP practices required to: Have a register of prostate cancer patients Conduct a quarterly search for patients with prostate cancer who are not under secondary care Offer a 30 min welcome appointment to all newly transferred patients within four weeks of notification of transfer from secondary care under the Time to Talk Cancer scheme Organise PSA testing as per the instructions on the patient’s Treatment Summary, review the results and organise follow-up testing or re-referral to secondary care as appropriate