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

4. 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).

5. 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.

6. Non-visible haematuria
Dr josh cullimore
Gp urology clinical lead

7. 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)

8. 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.

9. 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).

11. PSA & Suspected Prostate Cancer
Jhumur Pati
Consultant Urological Surgeon

12. 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

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

14. 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.

15. 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

16. 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

17. 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

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

19. 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

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

21. 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

22. 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)

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

24. Thank You !

25. 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 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

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

27. 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