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Health care practice and knowledge are constantly changing and developing as new research and treatments, changes in procedures, drugs and equipment become available.
The author and publishers have, as far as is possible, taken care to confi rm that the information complies with the latest standards of practice and legislation.
Essential Urology in
General Practice
Manit Arya, Iqbal S. Shergill, Nitika Silhi, Philippe Grange and Simon R. J. Bott Quay Books Division, MA Healthcare Ltd, St Jude’s Church, Dulwich Road, London SE24 0PB British Library Cataloguing-in-Publication DataA catalogue record is available for this book ISBN-10: 1 85642 372 7ISBN-13: 978 1 85642 372 4 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission from the publishers Foreword
Being a General Practitioner today is a challenging profession. The GP is often presented with a variety of urological conditions, having had no or little uro-logical experience. Many of these conditions are now dealt with in primary care – e.g. urinary tract infections, erectile dysfunction and female urinary incontinence. Unfortunately, there is no book currently available aimed prima-rily at GPs and trainees which satisfactorily covers this important fi eld. Having read through this book I would like to congratulate the editors on fi lling this void with a simple practical text which should be essential reading to all those professionals in and related to primary care. Of particular importance is that each chapter is written as a collaboration between GPs and urologists. In these uncertain, changing times it is important to establish and maintain relation-ships between primary and secondary care.
I would suggest that each practice obtains a copy of this book for its library. Indeed, perhaps many hospital departments would also benefi t from having a copy. In addition many GP trainees may benefi t from perusing this text prior to sitting the nMRCGP.
Principal GP Partner and GP Trainer, Crosby House Surgery, Slough Member of the Professional Executive Committee and Primary Care Lead, Berkshire East Primary Care Trust. Berkshire Local Medical Contents
Preface ix
Editors xiii
Contributors xv

Part I
Adult urology
Chapter 1
Erectile dysfunction
Jas Kalsi, Gus Cabre, Davendra Sharma and Suks Minhas Chapter 2
Vasectomy 15
Frank Chinegwundoh and Georgieana Cave
Chapter 3
Male infertility
Asif Muneer, David Jones and Suks Minhas Chapter 4
Urinary tract infection in adults
Paul Erotocritou, Sima Patel, Neehar Arya, Rizwan Hamid and Petros Erotocritou Chapter 5
Overactive bladder, urgency and stress urinary
incontinence in adult females

Pippa Sangster, Miles Goldstraw, Rajesh Kavia, Ketan Kansagra, Vinay Kalsi and Rizwan Hamid Chapter 6
Benign conditions of the scrotum and testis
Davendra Sharma, Gus Cabre and Philippe Grange Chapter 7
Ureteric colic
Hashim Uddin Ahmed, Paul Erotocritou, Shailesh Kulkarni, Peter Kraus and Matt Winkler Chapter 8
Benign and malignant skin disorders of the external
genitalia 77
Iaisha Ali, Mohamed Hammadeh, Shailesh Kulkarni,
Navroop Shergill and Asif Muneer

Chapter 9
Lower urinary tract symptoms and benign prostatic
hyperplasia 91
Neil Barber and Gordon Mackay
Chapter 10
Haematuria 101
Aza Mohammed, Blanca Martin-Retortillo, Jay Khastgir,
Sandy Gujral and Ignacio Zamora

Chapter 11
Bladder cancer
Andrew Robinson, Azhar Khan, Iqbal Shergill, Ann McDougall and Brian Waymont Chapter 12
Testicular cancer
Simon Gill, Hashim Uddin Ahmed, Shashi Kumar, Manit Arya and Jayanta Barua Chapter 13
Prostate specifi c antigen (PSA)
Chapter 14
Prostate cancer – localised disease
Simon Bott, Nitika Silhi and Alison Birtle Chapter 15
Prostate cancer – locally advanced and metastatic
disease 155
Simon Bott, Nitika Silhi and Alison Birtle
Part II
Paediatric urology
Chapter 16
The prepuce: normal development, phimosis and
circumcision 167
Nilay Patel, Vinay Kalsi, Asif Muneer, Nitika Silhi and
Imran Mushtaq

Chapter 17
Urinary tract infection in children
Shekhar Marathe, Jas Kalsi and Miranda Ruston Chapter 18
Urinary incontinence in children
Dawit Worku, Erdinc Havutcu, Jay Khastgir, George Fowlis and Rim El-Rifai Chapter 19
Cryptorchidism 193
Dawit Worku, Mohamed Hammadeh, Penelope Cox and
George Fowlis

Part III
Miscellaneous
Chapter 20
Urethral catheterisation
Rajesh Kavia, Vinay Kalsi, Christopher Blick, Jayanta Barua and Philippe Grange Chapter 21
The nature and the role of the General Practitioner
with a Specialist Interest (GPwSI)

Nitika Silhi and Aravinda Guniyangodage Chapter 22
Imaging techniques in urology
Christopher Blick, Miles Walkden, Nilay Patel and Asif Muneer Index 231
Urology forms a signifi cant proportion of primary care consultations. Most doctors and medical students have less and less exposure to this important speciality and so an easy, concise and up to date reference manual providing the essentials of urology in primary care is required.
We have produced this book for the busy General Practitioner and trainee with day-to-day practice in mind. Our aim is to promote a simple and practical approach to all urological consultations. This text will also provide an invalu-able source of information and guidelines on urological management which are logical and evidence based. We hope the scope provided by this book will be useful to those sitting the nMRCGP exam. The book will additionally be of considerable interest to specialist nurses, medical students and junior doctors in related specialities.
With these goals in mind each chapter has been written by a general prac- titioner in conjunction with a urologist and is heavily infl uenced by trainee co-authors. Where possible, the chapter begins with a case study followed by suggestions for important points in the history and examination. Relevant investigations and treatment in primary care are then discussed. Further man-agement of the condition in secondary care is mentioned in order to supple-ment the reader’s understanding and knowledge. A list of key points can be found at the end of each section.
This book has been an exciting and challenging project. We would like to give our heartfelt thanks to all of the authors for their time and hard work. To the reader – ‘Enjoy!’.
Subhash Arya and Saroj Arya, both of whom were devoted General Practitioners and who are now enjoying retirement. They have taught me, by example, to try and live my life with dignity. Mohan Singh and Surinder Kaur for their tireless support and sacrifi ces. Ranweer and Savita Silhi for always being there. I owe it all to them. Alan and Caroline, who have been there for me through thick and thin. Manit Arya FRCS, FRCS(Urol)
Senior Fellow in Laparoscopic Uro-oncology, Department of Urology, Division
of Surgical and Interventional Sciences, University College Hospital London,
Honorary Senior Fellow in Laparoscopic Surgery, King’s College Hospital, London,
and Research Fellow in Molecular Uro-oncology, Prostate Cancer Research Centre,
University College London.

Iqbal S. Shergill BSc (Hons) MRCS (Eng) FRCS (Urol)
Senior Specialist Registrar in Urology, St Bartholomew’s and the Royal London
Hospitals, London, and Research Fellow in Molecular Uro-pathology, Prostate
Cancer Research Centre, University College London.

Nitika Silhi BSc (Hons) MBBS MRCGP
General Practitioner, North East London, and Clinical Assistant in Genito-Urinary
Medicine, Northwick Park Hospital, Harrow.

Philippe Grange MD AIH ACCA
Consultant Urological Surgeon and Head of Section of Laparoscopic Surgery, King’s
College Hospital, London.

Simon R. J. Bott MD FRCS FRCS (Urol) FEBU
Senior Specialist Registrar in Urology, London.
Contributors
Hashim Uddin Ahmed MRCS (Ed) BM, BCh (Oxon) BA (Hons)
MRC Clinical Research Fellow, Department of Urology, Division of Surgical and
Interventional Sciences, University College London, and Specialist Registrar
Urology, Imperial College Healthcare NHS Trust, London.

Iaisha Ali MBBS MRCP
Specialist Registrar Dermatology, Churchill Hospital, Oxford.
Manit Arya FRCS FRCS (Urol)
Senior Fellow in Laparoscopic Uro-oncology, Department of Urology, Division
of Surgical and Interventional Sciences, University College Hospital London,
Honorary Senior Fellow in Laparoscopic Surgery, King’s College Hospital, London,
and Research Fellow in Molecular Uro-oncology, Prostate Cancer Research Centre,
University College London.

Neehar Arya, MBBS MRCS (Eng and Ed) FFAEM
Consultant in Emergency Medicine, Canada.
Neil Barber BSc FRCS (Urol)
Consultant Urological Surgeon, Frimley Park Hospital, Surrey.
Professor Jayanta Barua, MD FRCS Ed (Urol) FEBU
Consultant Urological Surgeon and Director of Research and Development, King
George Hospital, Barking/Havering/Redbridge NHS Trust, and Professor, South
Bank University, London.

Alison J. Birtle MD MRCP FRCR
Honorary Clinical Senior Lecturer and Consultant Clinical Oncologist, Rosemere
Cancer Centre, Royal Preston Hospital, Preston, Lancashire.

Christopher Blick MRCS
Research Fellow, Department of Urology, Churchill Hospital, Oxford.
Simon R. J. Bott MD FRCS FRCS (Urol) FEBU
Senior Specialist Registrar in Urology, London.
Sqn Ldr Gus Cabre LMS (Barc) FRCS (Eng) DRCOG DAvMed RAF
General Practitioner and Medical Offi cer Instructor, Royal Air Force Centre of
Aviation Medicine, RAF Henlow, UK.

Georgieana Cave MBBS DRCOG MRCGP
General Practitioner, Chingford, London.
Frank Chinegwundoh MBBS MS FRCS (Eng & Ed) FRCS (Urol) FEBU
Consultant Urological Surgeon, St Bartholomew’s and the Royal London NHS Trust
& Newham University Hospital NHS Trust, London.

Penelope Cox MBBS MRCGP DRCOG DCH DFSRH
General Practitioner, Edgware, London.
Rim El-Rifai MD MRCPI FRCPCH DPMSA
Consultant Paediatrician and Neonatologist and Honorary Senior Lecturer in
Paediatrics, Queen Mary’s Hospital for Children, Epsom & St Helier University
Hospitals NHS Trust, Carshalton, Surrey.

Paul Erotocritou MBBS MRCS
Senior House Offi cer, Urology, Whittington Hospital, London.
Petros Erotocritou MD SIM (Athens)
General Practitioner, Bramingham Park Medical Centre, Barton Hills, Luton.
George Fowlis BSc (Hons) Yale MD FEBU FRCS (Urol)
Consultant Urological Surgeon, North Middlesex University Hospital, London.
Simon Gill BSc MBBS
Senior House Offi cer, Imperial College Healthcare NHS Trust, London.
Miles Goldstraw BSc (Hons) MRCS
Specialist Registrar in Urology, London.
Philippe Grange MD AIH ACCA
Consultant Urological Surgeon and Head of Section of Laparoscopic Surgery, King’s
College Hospital, London.

Aravinda Guniyangodage MBBS MRCGP DFSRH DRCOG
General Practitioner, Brentwood, and Programme Director, King George Hospital
Vocational Training Scheme, Essex.

Sandy Gujral MS FEBU FRCS (Urol)
Consultant Urological Surgeon, King George Hospital, Barking/Havering/Redbridge
NHS Trust.

Rizwan Hamid FRCS FRCS (Urol)
Senior Fellow in Urology, University College Hospital, London.
Mohamed Y. Hammadeh MSc (Urol) FEBU FRCS (Eng., Urol)
Consultant Urological Surgeon, Queen Elizabeth Hospital, London.
Erdinc Havutcu MD MRCOG
General Practitioner, Palmers Green, London.
Richard G. Hindley MSc FRCS (Urol)
Consultant Urological Surgeon, Basingstoke and North Hampshire NHS
Foundation Trust.

David Jones MRCP MRCGP DRCOG
General Practitioner, Witney, Oxfordshire.
Jas Kalsi BSc (Hons) MBBS (Hons) MRCS (Eng) MRCSEd FRCS (Urol)
Specialist Registrar in Urology, University College Hospital, London.
Vinay Kalsi MBBS MRCS
Specialist Registrar in Urology, The National Hospital for Neurology and
Neurosurgery, Queen Square, Great Ormond Street Hospital for Sick Children,
London, and University College Hospital, London.

Ketan B. Kansagra BSc MBBS DRCOG
General Practitioner, Crawley, Surrey.
Rajesh B. C. Kavia BSc (Hons) MBBS (Hons) MRCS
Specialist Registrar in Urology, Hillingdon Hospital, London.
Azhar Khan MBBS MRCS
Specialist Registrar in Urology, New Cross Hospital, Wolverhampton.
Jay Khastgir MBChB MS FRCSEd FRCS (Glas) PGCertEd FRCS (Urol)
Consultant Urological Surgeon & Senior Clinical Tutor, Morriston Hospital ABM
University Hospitals Trust, Swansea

Shailesh Kulkarni MBBS MS MCh (Urol) MRCS FEBU FRCS (Urol)
Staff Grade in Urology, King George Hospital, Barking/Havering/Redbridge NHS
Trust.

Shashi Kumar MBBS DRCOG
General Practitioner and GP trainer, Chingford, and Honorary Clinical Lecturer, St
Bartholomew’s and the Royal London Medical School.

Peter D. Kraus MBBS MRCGP
General Practitioner and GP trainer, Kingsbury, London.
David M. Love MB BS DRCOG
General Practitioner, Hook and Hartney Wintney Surgery, Hampshire.
Shekhar Marathe, FRCS MSc (Urol)
Clinical Fellow in Urology, West Hertfordshire NHS Trust
Ann McDougall MB BCh MRCGP DRCOG
General Practitioner, Elstree, Hertfordshire, and Programme Director, Northwick
Park Hospital Vocational Training Scheme.

Blanca Martin-Retortillo LMS
General Practitioner, Whinfi eld Surgery, Darlington.
Gordon Mackay, MBChB DRCOG
General Practitioner, Crowthorne, Berkshire.
Suks Minhas MD FRCS (Urol)
Consultant Andrological Surgeon, University College Hospital, London.
Aza Mohammed MB ChB MRCS
Registrar in Urology, North Tees University Hospital, Stockton on Tees.
Asif Muneer BSc (Hons) MD FRCS (Urol)
Consultant Andrological Surgeon, University College Hospital, London.
Imran Mushtaq MBChB FRCS MD FRCS (Paed)
Consultant Paediatric Urological Surgeon, Great Ormond Street Hospital for Sick
Children, London.

Nilay Patel MD MRCS
Specialist Registrar in Urology, Churchill Hospital, Oxford.
Sima S. Patel MBBS
Senior House Offi cer, North Middlesex University Hospital, London.
Andrew Robinson MBBS
FY2 Doctor in Urology, New Cross Hospital, Wolverhampton.
Miranda Ruston FRCS (Urol)
Consultant Urological Surgeon, West Hertfordshire NHS Trust.
Pippa Sangster BSc MRCS MSc (Urol)
Specialist Registrar in Urology, Chelsea and Westminister Hospital, London.
Davendra M. Sharma MBBCh BAO MRCS MSc FRCS (Urol)
Specialist Registrar Urology, University College Hospital, London.
Iqbal S. Shergill BSc (Hons) MRCS (Eng) FRCS (Urol)
Senior Specialist Registrar in Urology, London, and Research Fellow in Molecular
Uro-pathology, Prostate Cancer Research Centre, University College London.

Navroop Shergill MBBS nMRCGP
General Practitioner, North-East London.
Nitika Silhi BSc (Hons) MBBS MRCGP
Clinical Assistant in Genito-Urinary Medicine, Northwick Park Hospital, Harrow,
and General Practitioner, North-East London.

Miles Walkden MRCS FRCR
Senior Specialist Registrar, Department of Radiology, University College Hospital,
London.

Brian Waymont MBChB MD FRCS
Consultant Urological Surgeon, New Cross Hospital, Wolverhampton.
Matt Winkler FRCS(Urol) MD
Consultant Urological Surgeon, Imperial College Healthcare NHS Trust, London.
Dawit Worku MD MRCS (Ed) MSc
Clinical Fellow General Surgery, North Middlesex University Hospital, London.
Ignacio Zamora LMS MD PhD
Consultant Urologic Surgeon, North Tees University Hospital, Stockton-on-Tees.
Adult urology
Erectile dysfunction
Jas Kalsi, Gus Cabre, Davendra Sharma and Suks Minhas Case history 1
A 65-year-old man attends his GP surgery with two-year worsening history of erectile dysfunction. Now having relationship problems. In desperation has used the Internet to order Viagra tablets. Has had no benefi t. Also complaining of increasing lethargy and tiredness.
On direct questioning also complains of loss of libido and confi dence. Normal examination. Morning serum testosterone is found to be low (7 nmol/l). His FSH, LH, prolactin and glucose are within normal limits. PSA 1.2. Started on testosterone replacement patches. Libido improves and erection signifi cantly better. Adds in Viagra again; now successful intercourse.
Case history 2
Twenty-nine-year-old male. Never been able to maintain relationship as cannot get a sustained erection. No history of trauma. No long-term partner. Family worried as getting very depressed.
On direct questioning good nocturnal erections and can get success- ful erections when masturbates. Normal blood tests and examination. Referred to a psychosexual counselor and had eight sessions over four-month period. Improved confi dence and starting new relationship.
Essential urology in general practice Case history 3
Seventy-year-old male. Never been to see the GP before. Recently returned from Thailand after getting married to 25-year-old lady. Has had gradually worsening erections for many years and now cannot get an erection at all.
On direct questioning, no early morning or nocturnal erections any more. Gradual onset of problem. Complaining of passing urine fre-quently day and night. Normal examination. Fasting glucose 9.2. Fasting cholesterol 7.7; PSA 2.5; BMI 30. Waist circumference raised. Started oral hypoglycaemic agents and lipid lowering agents. Currently using Levitra successfully.
Introduction
Erectile dysfunction (ED) has been defi ned as the persistent inability to attain and/or maintain an erection suffi cient for sexual performance.
ED is closely associated with many important physical conditions and may affect psycho-social health. As such, ED has a signifi cant impact on the qual-ity of life of patients and their partners. Several large epidemiological studies have shown a high prevalence and incidence of ED worldwide (see Further reading).
Increased awareness of the disease has resulted in more men seeking treat- ment from their GPs. Oral, intracavernosal and intraurethral pharmacological agents are now widely available in primary care. As a result, fewer patients require referral to urological surgeons, as surgical intervention has only a small specialised role in the overall management of ED.
Risk factors
Penile erection is a complex neurovascular event under hormonal control. The risk factors for ED (sedentary lifestyle, obesity, smoking, hypercholesterolemia and the metabolic syndrome) are common to the risk factors for cardiovascular disease. Furthermore, ED itself is a cardiovascular risk factor conferring a risk equivalent to a current moderate level of smoking.
A detailed description of the problem, including the duration of symptoms, should be obtained. Other factors that should be elicited are: „ Original precipitating factor(s)„ Predisposing factors„ Maintaining factors„ Any subsequent investigations„ Treatments, with the response achieved„ Enquiry regarding rigidity with quality of morning awakening erections, and spontaneous, masturbatory or partner-related activity erections „ Sexual desire, ejaculatory and orgasmic dysfunction„ Issues around any sexual aversion or sexual pain„ Previous erectile capacity„ Partner issues, e.g. menopause or vaginal pain„ Concurrent medical, psychiatric and surgical history„ Current relationship status and history of previous sexual partners and rela- „ Alcohol, smoking and illicit drug misuse In the history, sudden onset of ED, presence of early morning erections and erections during masturbation/with a different partner (if has one) point to a psychological rather than organic cause of ED. The use of validated ques-tionnaires, particularly the International Index of Erectile Function (IIEF) is advised to assess the baseline function as well as the impact of treatments and interventions.
Examination
All patients should have a focused physical examination. A genital examina-tion is recommended, especially if there is a history of rapid onset of pain, deviation of the penis during tumescence (suggesting Peyronie’s disease), the symptoms of hypogonadism or other urological symptoms. A digital rectal examination (DRE) of the prostate is recommended in the presence of genito-urinary or ejaculatory symptoms. Blood pressure, heart rate, waist circumfer-ence and weight should be measured in all patients.

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