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Icited by Ni; Lay Gu;:t & Lee Lili S!-:iong

Singapore

ffi#F General Hospital

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GONTENTS

1 Preface By The Editor 03

2 List Of Contributors o4

3 Rn Approach to Benign Prostatic Hyperplasia 05

and Lower Urinary Tract Symptoms
4 An Approach to Nocturia 17

5 Rn Approach to Urinary lncontinence 24

6 Rn Approach to Asymptomatic Microscopic Haematuria 28

7 Rn Approach to Asymptomatic Pyuria JJ

8 An Approach to PSA Screening 3B

I An Approach to Erectile Dysfunction 42

10 An Approach to Premature Ejaculation a-7

11 An Approach to Haematospermia

12 An Approach to Non-Traumatic Urological Emergencies 5B

13 An Approach to Late Onset Hypogonadism 62

14 An Approach to Renal Cysts ot

15 An Approach to Common Scrotal Conditions 78

16 Art and Real Life Clinical Practice OJ

17 The Continence Nurse in Urological Care B5

18 Tl're Urologic-Oncology Nurse [0 Patient Care 88

19 The Pelvic Floor Disorder Service 90

20 SGH Urology Centre Contact Number 93

21 Staff Profile 94

22 List of Sponsors 95

23 Notes 103

ir. :

.,)
.:,
 PREFAGE BY
THE EDITOR
It is with great pleasure that I pen this foreword. This book was
written in conjunction with the 25th anniversary celebrations o{ the
Department of Urology, Singapore General Hospital. Our department
was established in 1 988 by Professor Foo Keong Tatt. and is the first and
Iargest urology department in Singapore. ln the past quarter of a century,
we have challenged ourselves to be in the forefront of clinical setvice,
medical education and research. We also pride ourselves in being most
comprehensive, most specialised but the mosl approachable department!

A previous publication entitled "Urology & the Family Physician" by the

departrnent in 2001 was well received. ln this edition, over and above
updates in the speciality of urology, we have focused on discussing
selected conditions that are commonly co-managed between family
physicians and urologists. Such an approach is relevant and crucial in
contemporary medical practice, where a nrulti-disciplinary approach is
crucial for management of increasingly compler medical conditions.

We have had the privilege of extensive collaboration with other colleagues,

and this is reflected in each book chapter being co-authored between an
urologist and a family physician (or another specialist). I hope that this will
provide a more l.rolistic and comprehensive perspective for the reader.

Wjth these articles, we hope to provide the reader vvith a practical

approach to these conditions, so as to facilltate initial evaiuation and
assessment, and promote timely referrals when the need arises.

Happy readingl

Dr Ng Lay Guat
Head and Senior Consultant
Department of Urology
5ingapore General Hospital

August 2013
',

AII rights reserved. No part of this publication may be reproduced, stored in

a retrieved system,or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise, without the pnor
permission of the publisher.

Disclaimer
This book is intended {or educational purposes and not intended to replace
or substitute the advice o{ an expert professional.
i.
tsBN 98I-04-4206-8
llll
il PREFACE BY THE EDIIOR I AN APPROACH TO COMMON UROLOGICAT DISORDERS 3

I
,]..
 2 LIST OF GONTRIBI'TORS
UROLOGISTS / NURSES
Department o, Urology,
Dr Ng Lay Guat
Head and Senior Consultant
Prof Foo Keong Tatt
Emeritus Consultant
A/P Weber Lau Kam On
Senior Consultant
Dr Chong Tsung Wen
Senior Consultant
Dr Tan Yeh Hong
Senior Consultant
Dr Sim Hong Gee
Senior Consultant
Dr John Yuen Shyi Peng
Senior Consultant
Dr Henry Ho Sun Sien
Consultant
Dr Nor Azhari Bin Mohd Zam
Consultant
Dr Lee Fang Jann
Coneltant
Dr Lee Lui Shiong
Consultant
Dr Allen Sim Soon Phang
Registrar
Dr Valerie Gan Huei Li
Registrar
Dr Kenneth Chen
Resident
APN Juriyah Yatim
Senior Nurse Clinie-ian,
SGH Pelvic Floor Disorder Service
Ahmat
SSN Hamimah Binte
Continence Nurse
SSN Norlela Binte Hashim
U r olog i c- O n col ogy N u
PSYCHIATRIST
Department.of Psychiatry
A,/P Ng Beng Yeong
Head and Senior Consultant
4 AN APPRoACH To COMMON UROTOGICA. DISORDERS
3 AN APPROACH TO BENIGN PROSTATIG HYPERPLASIA
AND LOWER URINARY TRAST SYMPTOMS
Professor Foo Keong Tatt
FAMILY PHYSICIANS Emeritus Consu/tand Department of Urolog1q Singapore General Hospita/
SGH Department of Family Medicine
and Continuing care, sGH
INTRODUCTION
Dr Farhad Vasanwala
Consultant Although a common problem in urology, there are still gaps in our understandinq of the disease BPH.
ln autopsy study of men, 50% above the age of 60 years had 8PH (1 ). Not all patients with BPH have
Dr Ng Joo Ming Matthew LUTS and on the other hand, many patients with LUTS may not have BPH (2). ln our study on patients
Consultant with acute retention of urine due to BPH, 37.5% of them had only mild symptoms before the event (3).
Currently, with the widespread use o{ PSA testing in health screening, many patients with BPH present
SingHealth Polyclinics
with a raised serum PSA. ln fact, only 23% of patients with raised PSA more than 4 ug/1, are due to
Dr Gilbert Tan Choon Seng cancer on biopsy. The negative biopsies are due to BPH chronic prostatitis or a combination o{ both ( ).
Directott SingHea lth Polycl i n ics Thus, the clinician would need to make the diagnosis to predict the course of the disease. anci then
Geylang decide orr the treatment for the individual patient in real life practice. To do these, understanding BPH
and its basic pathophysiology is important.
Dr Hwang Siew Wai
Di rector, Si ng Health Polycl in ics
Bukit Merah
WHAT IS THE PATHOPHYSIOLOGY AND DEFINITION OF BPI{?
Dr How Choon How On histology, BPH is benign micronodular hyperplasia (5). The hyperplastic process is stimulated by
Di rector, Si ng Health Polycl in i cs dihydrotestosterone (DHT). The micro-nodules coalesce together to form biqger nodules (prostate
Sengkang adenoma). sinrilar to libroadenoma o{ the fernale breast. This occurs in the transitional and/or
periurethral zones of the prostate, thus giving rise clinically to the laterai lobes and/or the middle lobe.
Dr luliana Bahadin
These cause obstruction by distortion of the funrreling bladder neck and compression to the prostatic
Directot SinqHealth Polyclinics
ttrethra. Distortron causes more obstruction than compression. The disease does nol af{ect an entire
Bedok
zone, but is focal in nature. ihere{ore, the degree o[ oLrstructron depends nrore on the site of the
Dr Koong Ying Leng Agnes adenoma, rather than the srze. For example, the adenorna situated right at the bladder oLrtlet beneath
Directoc Si ng H ealth Polycl inics the mucosa causes more obstruction, as compared to the one situated deeper in the stroma. Stromal
Marine Parade adenoma would need to grow large enough to cause compression and significant obstruction. Thus this
explains why some small prostates can cause significant obstruction and some larger prostates do not.
Dr Peter Moey Kirm Seng
Directoti 5i ng H ealth Polycl in ics Therefore, cljnical BPH can be defined as prostate adenoma, irrespective of size. causing varying degree
Pasir Ris of obstruction with or without symptoms (6).
National University Health System
A/Professor Goh Lee Gan
HOW DO ! EVALUATE A PATIENT WITH SI.JSPECTED BPH?
Professorial Fellow Division of Family Medicine, For patients with LUTS, it is important to exclude other causes such as diabetes mellitus (DM). nocturnal
University Medicine Cluster NUHS polyuria, urinary tract infection (UTl) and over active bladder (OAB) as may the case in female patients
too. OAB can also be secondary to bladder outlet obstruction. It is important to identify this, and earlier
National Healthcare Group Polyclinics
treatment of bladder outlet obstruction leads to better chances of recovery. The development of urinary
Dr Tung Yew Chong frequency and urgency in a patient with BPH should raise the suspicion.
Head, National Healthcare Group Polyclinic
A careful Digital Rectal Examinatron (DRE), revealing a firm and smooth prostate, and a normal serum
Toa Payoh
prostate specific antigen (PSA) of less than 4 ug/L can rule out significant prostate cancer.
Dr Tan Hsien Yung David
Deputy Head, Healthcare Group Polyclinic Patients with abnormal DRE, and elevated PSA should be referred to the specialist for further evaluation.
lurong The positive predictive value of abnormal DRE, for prostate cancer is about 40% in a local study by Tan
Assistant Director, Family Medicine Development HH et al (4).
rx Division, National Healthcare Group Polyclinics
Fullerton Healthcare Group EVALUATING SYMPTOMS
SGH It is recommended that patients do the lnternational Prostate symptoms Score (IPSS) and the Quality
Dr Kwong Seh Meng
Deputy Head, Medical Operations, Fullerton
of life (QOL) questionnaire (Fig 1 ) (7). The IPSS consist of 7 questions relating to storage and voiding
Healthcare Group functions of the bladder, and the effect on the quality of life (Question B). The voiding symptoms
(prevrously termed obstructive synrptoms) are feeling of incomplete emptying. intermittency. poor
stream and hesitancy. The storage symptoms (previously termed irritative symptoms) are urgency,
I LIST OF CONTRIAUTONS AN APPROACH TO BtNI6N PROSTATIC HYPERPUSIA AND LOWSR URINARY TRAS SYMfrOMS I AN APPROACH TO COMMON UROLO6ICAL DISORDERS
 {requency and nocturia. There are five possible responses to the questions, from "not at all" to "all
the time", scoring from zero to 5. Therefore, the total score can vary from zero to a maximum of 35;
0 to 7 constitutes mild symptoms, 8 to 20 as moderate and 21 to 35 as severe symptoms.
Many international clinical guidelines still recommend the IPSS score as the main parameter for
choosing the modality of treatment. Patients with mild symptoms are watched, while those with
moderate to severe symptoms are treated with alpha blockers, or together with 5 alpha reductase
inhibitors (5 ARI'S). lf there ts no response to treatment, then more invasive procedures such as
thermotherapy and transurethral surgery are offered (7).
However, the QOL score may be more important than the IPSS score. This consists of 7 responses: a
score of O ( feellng delighted), to the highest score of 6 (feeling terrible). Though some patients may
have high IPSS scores, they may not be bothered (low QOL scores). For example, a retiree may not
be bothered by getting up 4 times at night to void, as he might be able to get back to sleep. On the
other hand, a young executive would be bothered if he had to wake twice nightly, as it might affect
his ability to work.
Most patients with LUTS consult the doctor mainly to find out ii they have cancer, or if their symptoms
would affect the function of their kidneys. lf they can be rcassured, many would be happy to be
watched, and accept the advice to adopt a healthy life style. To reassure them, apart from excluding
siqnificant prostate cancer, it is important to assess the extent of obstruction from existing prostate
adenoma. Severe obstruction by the adenoma would lead to dysfunction of the bladder and the kidneys.
EVALUATING OBSTRUCTIOt\{
This can be done in the Family Physician clinic tlrrough a detailed history of the urinary stream, such
as wlrether the stream can hit the wall of the urinal, or dribble between the legs. A more objective
way for the clinician is to watclr the patient void and assess the flow visually, but this may be socially
difficult. ln the specialist clinic, thc patient witlr a comfortably full bladder of about 200 to 300 mls
would have the srze and shape of the prostate assessed with trans-abdominal ultrasound (TAUS). The
patient is then asked to pass urine into the uroflourmetry machine, whrch would record the speed
of flow more objectively. For a proper flour test ideally, the volume voided should be more than 150
mls. A f low rate of less than 1 0 ml/s would indicate obstruction 90% of the time (8). The other
10% of patients may have poor bladder contraciicns due to detrusor dysfunction from causes such
as diabetic cystopathy, rather than prostate obstruction. A flow rate o{ more than 1 5 ml/s would
probably indicate no obstruction.
What is more important than flow rate is the assessment of the post void residual urine (PVR).
Persrstent post void residual urine o{ more than 100 mls would indicate that the voiding function
is affected and this may eventually affect the function of the kidneys from back pressure, such as
chronic retention of urine causing hydronephrosis (9). Such patients may have minimum symptoms
(IPSS) but have enuresis. Though not common, it is important to exclude chronic retention by careful
palpation and percussion for a distended bladder. ln the specialist clinic or if the family physician has
an ultrasound machine, the PVR can be easily measured. TAUS can also be used to assess the kidneys
for hydronephrosis. lf the patient has persistent residual urine, or the presence of a percussible or
palpable bladder, he should be referred to the specialist clinic for treatment.
Using TAUS, the size of the prostate can be estimated using the elliptical formula.
The shape, represented by the lntravesical Prostatic Protrusion (lPP) can be measured from the inner
most protrusion down to the base of the prostate at the circumference of the bladder. (Fig 2)
IPP is graded accordingly: 5mm or less as grade 1, > 5mm to 1Omm as grade 2, and >lomm as grade 3
ln 2003, Chia SJ et al (1 0) showed that using pressure-flow studies, of patients with grade 1 IPB 79%
of them were not obstructed. Conversely, for grade 3 IPP patients, 94% of them were obstructed.
This has been validated by other studres elsewhere (1 1), (12), (13)
6 AN APPROA'H TO UROTOGICAL DISORDERS I AN APPROACH TO BENIGN PROSTATIC HYPERPUSIA AND LOWER URINARY TRACT SYMPTOMS
'OMMON
In those presenting with acute retention of urine (ARU), the failure rate for trial off catheter is lower
in patients with grade 1 IPP at 36% compared with 69% rn patients with grade 3 IPP (14). Therefore,
patients in ARU who have grade 3 IPP would be better treated with surgery earlier, rather than have
repeated trials off catheter with conservative treatment.
For patients on non-surgical management, patients wrth grade 3 IPP were seven times more likely (than
qride t tee) to deteriorate in symptom scores, or develop high PVR and ARU. With a follow up of 32
months, 49% of patients with grade 3 IPP deteriorated in the study. However, the other 51 % of grade
3 IPP patients did not deteriorate, and therefore, there is also a risk of over-treatment if IPP was the sole
parameter used to decide treatment options (1 5).
HOW SHOULD TREATMENT OF BPH BE INDTVIDUALISED?
Treatment should be based on whether BPH is affecting the function of the bladder or kidneys,
or causing bothersome symptoms to the patients. lf such is minimal risk, with no persistently hiqh PVR
and no bothersome symptoms, patients can be reassured and advised on fluid adjustments and healthy
lifestyle measures (exercise and diet).
Thus in our Ministry of Health guidelines, the treatment of BPH is tailored to the severity of the disease
(16). The severity can be staged according to the presence or absence of signrficant obstruction and
bothersome symptoms (1 7).
Significant obstruction is defined as persistent post void residual urine more than 1 00 mls, (or the
presence of a clinically palpable bladder). AIso, significant obstruction is suspected in patients who
persistently pass small quantities of urine less than 1 00 mls and have frequency and urgency,
indicating bladder overactivity.
STAGING OF BPH
Stage l: Patients with no significant obstruction and no bothersome symptoms.
They can be watched and counseled.
Stage ll: Patients with no significant obstruction but has bothersome symptoms.
They would be considered for medical treatment.
Stage ll!: Patients with significant obstruction, irrespective of severity of symptoms would require active
treatment with options of surgical intervention.
Stage lV: Paticnts with complications of BPH such as acute and chronic retention of uflne, recurrent
UTl, or gross haematuria, and bladder stone formation. They would generally need surgical intervention.
MED!dAL THERAPY
There are two main groups of drugs used in treating BPH/LUTS:
*
1. AIpha blockers: such as Alfuzosin (Xatral), Terazosin (Hytrin), and Tamsulosin (Harnal). They relax
the smooth muscles of the bladder neck and the prostate.
2. 5 Alpha reductase inhibitors (sARl s): Frnasteride (Proscar) and Dutasteride (Avodart). They prevent
the conversion of testosterone to dihydrotestosterone which stimulate the growth of BPH.
The alpha blockers are good only for symptomatic treatment. They have not been shown to prevent
the progression of the disease BPH (1 8).
Some alpha blockers claim to be more uro-selective than others, but would still cause postural
hypotension and giddiness in up ro 14% of patients (7). ThereJore, they should be given cautiously
especially in elderly patients prone to falls. Although numerous studres have showed their effectiveness
in reducing the average IPSS, the percentage ol patient who benefited is still not well documented.
Therefore, in patients who are bothered by their symptoms, the medication can be given a trial of
not more than 2 to 4 weeks and then reassessed for response. lf patients find it effective with no side
effects, then they can be prescribed for longer period of time.
AN APPROACH TO BENIGN PROSTATIC HYPERPUSTA AND LOWER URINARY TRACT SYMPTOMS I AN APPROACH TO COMMON UROLOGICAI DISORDIRS 7
 Recent studies by Park HY et al 20'l 2 have shown that the alpha blockers are more effective in
pataents with grade 1 than grade 3 IPP (19).
s-Alpha Reductase lnhibitors (5 ARI's) have been shown to rcdu.c the size of the prostate and the
incidence o{ acute retention of urine (20).
They are only effective for prostate more than 30 grams (clinically palpable large prostate). They are
not effective for small glands.
The 5 ARI's need to be taken for at least 3 months in duration,before any discernible effect is expected.
There{ore, patients need to be counseled on lifelong therapy. Thus the 5 ARls should generally be reserved
for patients with stage lll BPH and large prostate volumes more than 30 grams. The side effects include a
loss of libido, elaculation failure and erectile dys{unction in 1 0% o{ patients. A recent rcport by Roehrborn
et al (2'l) showed that combination therapy with an alpha blocker (tamsulosin) and 5 Alpha reductase
inhibitor (dutasteride) is effective in reducing urinary symptoms and prostate size. and therefore, the
progression o{ BPH. However, the reported adverse events are also increased witlr combination therapy
(26% o{ patients), as compared to tamsulosin alone (15%) and dutasteride alone (9%). Therefore for
elderly patients, the combination therapy can still be prescribed but only after weighing the risks, benefits
and cost. lt may be useful in the subset of patients with bothersome symptoms and large prostate sizes
(more than 40 grams), who show good response to initial alpha blocker monotherapy with no side effects.
to have less side effects than dutasteride (22) and is now cheaper in
Finasteride (Proscar) is said
Sinqapore. However, the half-life of Proscar is 6 to 8 hours whereas dutasteride is about 5 weeks.
Therefore there may be less concern with using dutasteride especially when daily patient compliance
is difficult (7).
The 5 ARI's can reduce prostate size but cannot correct the shape of the prostate, which contributes
more significantly to obstruction. Tlrere{ore, in t)atrents with high grade IPP and small prostate
volumes, they may he better treated with surgery for high stage disease. Only a surgical option can
restore the prostate to its normal shape and configuration.
SURGICAL THERAPY
Surgery would be indicated for patients with retention of urine (acute and chronrc), and those with .
deterioration of symptoms not responding to medical treatment. A deterioration of IPSS (of 4 or
more points) and QOL scores suggest the possibility of OAB and bladder storage failure. Despite the
trend to treat these patients with anti-cholinergic agents such as oxybutynin (Ditropan), tolterodine
(Detrusitol) and solifenacin succinate (Vesicare), they may precipitate urinary retention and should be
used with caution.
lf OAB develops secondary to obstruction, the appropriate treatment should focus on relieving the
obstruction (BPH) rather than treating symptoms.
Transurethrat resection o{ Prostate (TURP) is still the standard surgical treatmentlor prostate
adenomata causing signi{icant obstruction. The morbidity and mortality oI the procedure have been
reduced over the years with the development ol urology in Singapore. The biood trans{usion rate
was reduced {rom 44% in the 1970 s to 4olo in the 1990's (23). Also, with the advancement of new
technology su(h as bipolar diathermy, TURP can be performed with normal saline for continuous
irrigatton during resection. This has elirninated the serious problem of TUR syndrome due to excessive
absorption of electrolyte solutions such as glycine or dextrose. This has also further reduced the
transfusion risk to existing rales ol 1Y" (24).
8 AN APPROACH TO COMMON UROLOGICAL DISORDERS I AN APPROACH ]O BENIGN PROSTATIC HYPERPLASIA AND LOWER URTNARY TRACT SYMPTOMS
Most patients are admitted on the day of surgery, and the length of stay is about 2 days. The
complicatrons encountered include peri-operative bleeding. with the need {or re-interventictl at less than
2olo. Serious post-operative sepsis is less than 2% (24). Temporary incontinence rate is about 4 70 and
permanent incontinence less than 1%. The mortality rate is rare at less than 1%.
On longer term follow up, urethral strictures and bladder neck stenosis may occur in 2 to 5% of patlents.
Recurrent prostate adenomata giving rise to recurrent symptoms and haematuria can be a problem, with 3
to 1 5% of patients requrring intervention in 5 years (25).
To reduce the problem of recurrent adenoma, Transurethral enucleation and resection of prostate
(TUERP) has been introduced recently. (26)TUERP mimics open prostatectomy, enucleating the prostate
adenoma endoscopically with the tip o{ the resectoscope sheath after {inding the correct plane. This
removes the prostate adenoma more completely and can also better control penoperative bleeding.
Temporary incontinence rate is higher at aboul 14o/o (271.
Laser Prostatectomy: Holmium laser can be used to enucleate the prostate adenoma (Holep). This has
been done in other centres and widely reported, and have good long term results (28). TUERP essentially
does the same job withour the need for the laser, thus it is less expensive and more practical.
Laser vaporization: Green light laser is associated with less bleeding, but does not remove the prostate
adenoma completely. The long term recui'rence rate is higher, and as high as 1B% of patients require
re-operation in 12 months (29).
Open Simple Prostatectomy is seldom per{ormed in Singapore, as it is more invasive with nrore post-
operative pain.
One cornmon side effects of surgery is retrograde ejacrrlation in most patients after prostatectomy.
Though not harmful, some patients find it less pleasurable during orgasm and can be distressful for
them if not warned be{oreharrd. However, surgery should not cause erectile dysfunction, though it has
been reported to be about 4 to 5o/o.
other minimally invasive procedures:
Transurethral microwave thermotherapy (TUMT): TUMT had been used by our Department for ten
years previously but it was found to be ineffective for the truly obstructing prostate. The recurrence rate
was high and we have stopped using the procedure (30).
Transurethral needle ablation (TUNA) is still investigational.
Practical steps in the evaluation of LUTS/BPH at the Family Physician Clinic
1. Age: Clinical BPH usually occurs after the age of 45 to 50 years. ln the younger age group, a
urethral stricture should be considered as a possible differential diagnosis, and
in the older age group, that of "aging bladder" and nocturnal polyuria.
2, IPSS and QOL scores: Although designed for self-administration, patients in our local context
may need help from the nurse or physrcran. These scores give an idea of the severity of LUTS and
the most bothersome symptoms. On follow up, these scores can give accurate documentation of
patrents' progression or deterioration. The deterioration of symptoms especially frequency and
urgency may indicate development oi OAB.
3. Palpate and percuss for a distended bladder: A clinically detectable bladder, immediately after
urination, indicates significant residual urine. This is suspicious for significant obstruction, whrch would
need aggressive treatment and a referral to the urologist.
4. Observation of the voiding process: This would give an estimate of the flow rate and severity
of obstruction. The vcliding time can also be measured, and normal values are about 20 seconds.
AN APPROACH TO BENIGN PROSTATIC HYPENPLASIA AND LOWER URINARY TRACT SYMPTOMS I AN APPROACH TO COMMON UROTOGICAI. DISORDTRS 9
 5. Digitai Rectal Examination (DRE) is important in differentiating BPH (which feels firm and ACKNOWLEDGEMENT
smooth) from malignancy (which feels hard and irregular). The positive predictive value of an Thanks to Dr Huang Honghong and Mr Norman Goh for assisting in editing the manuscript
abnormal DRE is 40olo, which is better than that of an elevated PSA level (above 4 uglLl al23o/o'
(4) DRE can also provide an esrimation of the prostate size, although it tends to underestimate the
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ran reasonable be excluded if DRE is normal and PSA within the normal range o{ < 4 ug/L
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a) Watchful waiting: lf the patient has no palpable bladder and not bothersome sylnptoms, he can
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d) Thus if a patient has a large prostate with significant obstruction, or symptoms not improving prostatic enlargement. Urology. 2OOl ; 7O: 1096-1099.
with medication, he should be referred to the urologisl to discuss surqery 13. Franco G et al. Ultrasound Assessment of Intravesical Prostatic Protrusion and Detrusor Wall
Thickness-New Standard for Noninvasive Bladder Outlet Obstruction Diagnosis? J Urol 2010; 183;
ln patients with a clinically detected bladder or no response 1o alpha blockers with deterioratron of 277 0-227 4
symptomsalteratrial oI 2lo4weeks,theyshouldbereferredtotheurologistforevaluation 14 Tan.YH et al. Intravesical prostatic protrusion predicts the outcome of a trial without catheter
following acute urine retention. J Urol 2003; 170:2339-2341.
cot-,lcLtlsloN 1 5. Lce LS et al. lntravesical prostatic protrusion predicts clinical progression of benign prostatic
with befter understanding of the pathophysiology of the disease, clinical BPH can now be diagnosed enlargement in patients on nonsurgical treatment lnt J Uro{-2010; 11:69-74.
more accurately with a combinatlon of estimating the prostate size, shape, arrC flow rate rather than 16. MOH clinical guideline for LUTS/BPH 2005
(if available)
relying on lp5S alone. Prostate consistency anC size can be assessed by DRE alone, but TAUS 17 . Foo KT. Current assessment and proposed staging of patients with benign prostatic hyperplasia.
is more accurate in ascertaininq prostate size, shape (lPP) and PVR. IPP helps in the diagnosis,
prediction
Ann Acad Med Singapore. 1995,24(4):648-651
of obstruction and progression of the disease. 1 8. McConnell J et al: The iong-term effect of doxazosin, finasteride, and combination therapy on the
clinical progression of benign prostatic hyperplasia. N Engl J Med. 2Oo3;349:2387.
The treatment of the disease should be managed according to severity. The severity of the disease can 19. Park HY et al. Efficacy of alpha blocker treatment according to the degree of intravesical prostatic
be classified according to the stage, such as Whether there is significant persistent reslduai urine with protrusion detected by transrectal ultrasonography in patients with benign prostatic hyperplasia.
a palpable bladder, or whether the symptoms are bothersome. Many patients are more concerned Korean J Urol. 201 2 February; 53(2): 92-97 .
about the possibility of prostate cancer. or whether their symptoms will deteriorate and affect kidney 20. RoehrbornCetal.Theeffectsofdutasteride,tamsulosinandcombinationtherapyonlowerurinary
function. lf they can be reassured, medical therapy may not be needed. Our recent study showed that tract symptoms in men with benign prostatic hyperplasia and prostatic enlargement: 2-year results
with proper stagin g, 59oh ot patients with LUTS/BPH can be safely watched, 29Y" treated with alpha from rhe CombeT stu.iy. J Urol. 20oa; 179. e'16
blockers, 6% with 5 ARI'S and 97o require surgery (31). After a specialist assessment,
patients with stage
referred back to the Family Physician {or follow up. 21 . Roehrbrorn CG et al. Ctinical outcomes after combined therapy with dutasteride plus tamsulosin
Iand ll disease, and with Grade 1 and 2 IPP can be
or either monotherapy in men with benign prostatic hyperplasia (BPH) by baseline characteristics:
Thus, with a proper definition, diagnosis and classification of clinical BPH, there would be better balance
4-year results from the randomized, double-blind Combination of Avodart and Tamsulosin
and cost-effectiveness in patient treatment

AN APPROACH TO BENIGN PROSTAT'C HYPERPUSIA AND LOWER URINANY TRAfr SYMPTOMS AN APPROACH TO COMMON UROTOGICAL DI5ORD[R5 l1
AN APPROACI] TO COMMON UROLOGICAL DISORDERS I AN APPROACH TO BENIGN PROSTATIC HYPTRPLASIA AND LOWEN URINARY TRACT SYMPTOMS
I
 (CombAT) trial. BIU lnt. 2011 Mar; 107(6):946-54. ALGORITHM FOR AN APPROACH TO LUTS/BPH FOR THE FAMILY
22 Kaplan SA et al. A s-year retrospective analysis of 5 o-reductase inhibitors in men with benign PHYSICIAN CLINlC
prostatic hyperplasia: finasteride has comparable urinary symptom efficacy and prostate volume
reduction, but less sexual side effects and Lrreast complications than dutasteride. lnt J Clin Pract.
2012 Nov; 66(1 1):'i052-5. doi: 10.1 111/1.1742-1241.2012.0301u.x.
Lim KB et al. TURP throuqh the decades. A comparison of TURP results over the last 30 years in
a single institution. Ann Acad Med Singapore. 2004;33:775-9.
Ho H et al. Prospective randomized comparison of bipolar TURIS (Transurethral Resection IPSS, Q0L, percuss for btadder, DRE, Labstix, PSA
in 5aline) and monopolar transurethral resection for benign prostate hyperplasia. European
Urology. 2007; 52: 517-524.
25 Rassweiler J et al. Complications of transurethral resection of the prostate (TURP) - incidence,
management, and prevention. Eur Urol. 2006; 50: 969.
t6. Llu C et al. Transurethral enucleation and resection of prostate in patients with Benign Prostatic
Hyperplasia by Plasma Kinetics. J Urol. 2010; 184,2440-2445.
21 Zhang KY et al . Bipolar plasmakinetic transurethral resection of the prostate vs. transurethral
enucleation and resaiction of the prostate: pre- postoperative comparison of parameters used in No ctinicatly detected bl.adder
assessing benign prostatrc enlargement. Singapore Med J. 20'l 1 ; 52(1 0): 7 47 -751 .

26. Neill MG et al. Randomized trial comparing holmium laser enucleation of prostate with
plasmakinetic enucleation of prostate for treatrnent of benign prostatic hyperplasia. Urology.
2006;68(5): 1020-4.
29. Horasanli K et al. Photoselective Potassium Titanyl Phosphate (KTP) Laser Vaporlsation
Versus Transurethral Resesction of the Prostate for Prostate larqer than 70 mls: A short-term
prospective randomized trial. Urology. 7OO8; 7 1 (2) 247.-251 .
30 Lee KT et al. Transurethral microwave thermotherapy (TUMT) for benign prostatic hyperplasia
(BPH) - Our First 1 00 Cases. SMJ. 1 995; 36: 1 81 -1 84.

31. Wang D et al. Staging of benign prostate hyperplasia is helpful in patients with lower urinary
No Bothersome Symptoms Bothersome Symptoms
tract symptoms suggestive of benign prostate hyperplasia. Ann Acad Med Singapore. 20'10;
39:798-802. 00L less than 3 QOL more than 3

Watch and
Smat[ prostate Patpabte [arge prostate
cou nseI
IMore than 30 to 40 grams)

Atpha btocker A[pha btocker +

5AR I's

,*.*"*[-*-.-
I
&"
 Figure 2. Transabdominal ultrasound measurements of intravesical prostatic protrusion (lPP)
Figure 1. tPSS & QOL score sheet

lnternationat Pro5tate score sheet llPssl

Not at at[ LeEs than LesS than About hatf Mor€ than Atmosl
Over the past month: 1

in 5times hetf the tim( the time hatf the time

Grade 1 IPP
l.How often have you had a sensation of not emptylng
your btadder comptetety alter you finish urlnatrng? 0 ? L 5

2. How olten have you had to urrnate agaln less

than 2 hours alter urrnaiing 0 1 2 3 4 5

3. How often did you find yoursetf stopping and

startlnq aqain seceraI times when you urlnaie? 0 1 2 3 5

4. How often have you found it diificutl

to postpone urioation? 0 t 2 3 4 5

2 3 /. 5
5. How often have you had weak urinary stream? 0 1

6. How often have you had to Push of

strain to begrn urrnation 0 2 3 A 5

7.How many times did you typrcaLLy 9e( up to urrnate

5or
from when you went lo bed al night untit you got up more/
tn the morninq? 0/nisht 'ilniqht 2/night 3/niqht /'/night night

Prostate Volume: Prostate Volume:

0 2 3 5
9.7 mts 62 mLs
IPP Grade 0: Omm IPP Grade 1: 3 mm
0etiqhted Pteased l"lostty NeutraL MosttY Unhappy Terribte
ouatity ol tite l0oll owihg to
satisfied dissatistie
urinary symptoms
Grade 2 IPP Grade 3 IPP
lf you had to spend the re5t of your [iie with your 5 6
0 2 3 4
condition as it rs now. how wo!td you feeI about it

E er Hirtll Strtl* {IPSS) i+r}*

ar) qr

eeiE-f E 6r, 1EE6€ l.)lTtrlri? )i o+-x I rr rr,: | I ,++e I rlryb;

^,!{$
0 3 I
F6'?H6l'N4,3ts?
0 3 5
2. ffi )tfl E,fi lBlIEEAriH4\+@4\E.f?
2 3 5
3. E?5-B !+fi tEl ffi ttIFE? 0

0 2 ?, 5
4. E6E.flFET6Eefffi$*?

s. E6€ffi4i*rflII'.*? 0
--- 2 3 4

4
Prostate Votume: 24 mls Prostate Votume: 38 mts
6. E6#EH r&{FSn *lr#.hlB? 0 l 2 3

4X s)i
IPP Grade 2: 9mm IPP Grade 3: 17 mm
7. U,\riESrl+fre-rsm*E*frtr,EnX? isa r)i 2;x 3,t

0 l 2 3 4 5 BPH GRADINJG ACCORDING TO IPP

frfiEi+a=
Grade 1 IPP: < 5mm
Grade 2 IPP: > 5 - 10 mm
ti66ErES(aoL)i+,}*
Grade 3 IPP: >10mm
iffiE i9ifr.E iIEIT)( zirk;fiH tqifi fRig

t0xE1s9 tra!trE +rh^i+8 1[EA!it 0 2 3 5 6

EfiU, lei hl!ftI?
t)*ffi&i+}}(aoLi=

ANAPPROACHTOBENIGNPROSTATICHYPERPLASIAANDLOWERURINARYTRACTSYMPTOMS
14 AN APPROACH TO COMMON UROLOGICAT DISORDERS I AN APPROACH IO BENIGN PROSTATIC HYPERPUSIA AND LOWER URINARY TRACT SYMPTOMS IANAPPROACHTOCOMMONUROLOGICALDISORDERS 15
 AN APPROACH rO BPH: A FAMILY PHYSICIAN'S PERSPE0TIUE 4 AN APPROACH TO NOGTURIA
Dr How Ghoon How Dr Ng Lay Guat
Director and Famity Physician, Senior Consultant, Head and Senior Consu/tant Depaftment of Uro/ogy, Singapore General Hospital
SingHealth Polyclinics, Sengkang Polyclinic
WHAT IS NOCTURIA?
INTRODUCTION Nocturia is defined by the lnternational Continence Society (lCS) as'waking up at night to void'(1) and
Benign prostatic hypertrophy (BPH) is commonly faced by older men in our community. As the li{e night is defined as 'the period of time of going to bed with an intention to sleep. to waking wrth an
expectanCy of men rn Singapore Continues tO rise, we can expect a higher prevalence of patients intention to rise regardless of when this period occurs'. This symptom appears to be present in both
presenting with lower urinary tract symptoms due to BPH. gender and progressively more common with age. Holever, the level of bothersomeness is worse for
the younger age group (2).
Many asymptomatic men may have been previously diagnosed with BPH after being evaluated {or
a raised prostate specific antigen (PSA) level during routine health screening. The U.S. Preventive This condition is a common symptom and can also be a major cause of bother to the patient in terms of
Services Task Force (USPTF) updated their recommendations in 2008 to discourage the routine use of sleep quality, day time sleepiness and overall detrimental impact on healllr and economy. Direct ill effects
PSA screening for prostate cancer in younger men. This should lead to a corresponding decrease in of nocturia include depression, daytime somnolence and reduction in productivity. ln the elderly, there is
the diagnosis of asynrptofi\atic men with early BPl l. an increased risk of falls, fractures and its subsequent morbidity and mortality (3).

Our current clinical practice guidelines recommend individualised treattrent of BPH based on the
severity of urinary obstruction and bothersome symptoms. The lnternational Prostete symptoms
Score (tpSS) and the Quality of life (QOL) questionnaire allow family physicians to per{orm a severity
assessment easily and monitor these patients over time. Between the two measures, clinicians should
pre{erentially use the QOL score as it re{lects how the individual's life is affected, regardless of the
severity of storage cr voiding symptoms reported.
ln a situation where the clinical condition is complicated (such as renal impairment from BPH, or
suspected concomitant urological malignancies), the Family Physician may co-manage their patients
with a urologist. Those with mild BPH can usually be managed in the community with regular
monitorinq and titration of oral medications. They should be re{erred to their attending urologist to
discuss surgical options when there is disease progression. ln this way, the maiority of patients wlth
BPH can be managed at the community level.
HOW DO WE EVALUATE A PATIENT WITH NOCTURIA?
There are rnany causes of nocturia and spans across multiple disciplines. The optimal management
at the primary care level relies on the ability to identify the causes, and channel patients to the
appropriate disciplines.
The key with history taking involves clarifyinq if the symptoms are purely nocturnal or global. Details
such as insomnie, sleeping habits and whether the wakening was due to urgency or for other reasons
will aid in the differential diagnoses. History of snoring or apnea from the spouse is important in
the diagnosis of possible obstructive sleep apnea. Also medical history such as that of congestive
heart disease, diabetes mellitus, renal rmpairment, varicose veins, obesity etc are impor[ant. Detailed
assessment of lower urinary tract syrnptoms rs a n]ust.
Physical examination invohres assessment of the patients BMl, targeted examination of the lower limbs
to assess for lower lin-rb edema, and presence o{ varicose vcins. Other assessment rncludes examination
of the bladder, prostate and in females, a detailed vaginal examination.

The management of nocturia anchors mainly on the patient's quality of life and the risks of further
morbidity and mortality. The most important tool is that of a bladder diary (4). This is a 3 day self
reported diary where patient or caregiver records the patjents intake in terms of beverage type, volume
and time and voiding habits (voided volume, time of void and associated symptoms of urgency and
incontinence). Figure 1 below shows a typical voiding diary and figure 2 shows a typical diary of a
patient with nocturia. Note the significant amount of urine produced between midnight and 7am
(sleeping iinre).

The voiding diary is the most reliable tool to differentiate between those with small bladder capacities
(leading to global urinary frequency), nocturnal polyuria (nocturnal urine outilut is >30% of totai 24
hour urine output). polyuria or mixed symptoms.

URINAR] 'TRACI ANAPPROACHTONOCTURIA IANAPPROACHTOCOMMONUROLOGICALDISORDERS 17

16 AN AIPRoACH 1o coMMON UROLOG\CAL DISORDERS \ AN APPROA(H TO BENTGN PROSIA'TIC HYPERPLASIA AND LOWER
 Fiqure 1. Typical voiding diary detailing intake and output Figure 2. Typical voiding diary for a patient with nocturia

CONTINENCE NURSE
E!ts
tvi), wlT
En tbt llr Bd lE-l $1 timi
l0'lbu t h0u- lc'\t)a L0oL L
Luta l0x
Tr?es ofrlsrdi bke.
IOD{,L l l.\t l LL(iC 1,tr )oo<t
I );h iv I tl, Ll, I ).!0 , It0Q E.t( lo t,
).lttn ll|LL ltfr L
q-t( lo cr-
?.Voa t nlL )u(i IEoLL n-x \7)LL
V'k( i^ kot.t, V'-6 n ll0c-L r),u loocL
PU Bnge:
tr'j 0n(- >.{4) t00(*
k.to^ IhD/ L t\tt lDo(L
la,qn tDbu, dl;r loccL fvo l)a( L
Iri? l\De 5oc- Jlw lloci-
)'fi* luurt- 1ot. l'Vr I )occ
;+.t{t lta cL lt.la J-0 c; V.r,o IOLL
.fr( Ito Lu l-Yor. .lr11l l9ot t 1-x tto(L
Nocturia:

tnr€ryal tie
Lo* k'toa looL Iu* 'au-
I

L't od ',kou tL.),o hau

-.t'10 lncoilincnt .pisodcs:
lo0CL )zto )oooi
1-V( loo Ct t-vJ httcc
J.bb, >10 LL
Amount ofplds sr.d

$t tt

rl

; 18 AN APPROACH TO CON1M1ON UROLOGICAL DISORDERS I AN APPROACH TO NOCIURIA AN APPROACH TO NOCURIA I AN APPROACH TO COMMON UROLOGICAT DISORDERS 19
l
 Figure 1. Typical voiding diary detailing intake and output WHAT CONDITIONS MAY MIMIC NOCTURIA?
Small bladder capacity
The cause o{ srnall bladder capacity whether global or nocturnal is usually urological. This may be due
to problems of bladder outlet obstruction, causing high post void residual urine. Other problems rnclude
NOCTURIA an overadive bladder, neurogenic bladder, or structurally contracted bladders due to urinary tuberculosis
or radiation therapy. Other forms of irritation to the bladder such as bladder or ureteric calculi, bladder
tumours etc can also lead to similar symptoms. These patients are best referred to the urologists for
further assessment.
Frequency-vo[ume chart
Nocturnal polyuria
Nocturnal polyuria is defined as passing more than 20-30% of his total 24 hours urine output in the
night. The normal nocturnal urine output ratio in young patients is about 20% and for the elderly, up to
3070 is acceptable. The causes of nocturnal polyuria are listed in the figure 3. Medical conditions leading
to fluid retention or peripheral edema, such as congestive cardiac farlure, result in increased intravascular
Low NBC l<200 mt
NocturnaI polyuria: Potyuria: 24-h volume when patients assume a recumbent position in the night. Obstructjve sleep apnea can cause
NPi ,33% votume ,40 mt/kg
or NBC| >21 q nocturnal polyuria from increased intrathoracic pressure and increased secretion of the atrial natriuretic
Low GBC hormone from the right atrium. This, in turn, leads to diuresis and nocturnal polyuria. lt is noteworthy
{MW <200 mt) that snoring alone is not diagnostic of OSA.
Overnight water M uLtipte
d eprivati on incrementaL ln other situations, the elderly may have nocturnal polyuria that occurs spontaneously, in the absence of
aetioLogies as CCF. DM or OSA. This is attributed to the loss of the usual circadian secretion of anti diuretic horrnone
per individuaI at night. As a result, the elderly individual produces relatively more urine in the evening and night.
Congestive unne >800 urine <800 nocturia
heart faiture m0sm/kg m0sm/kg categ ori es Polyuria
Occasronally, nc,cturia may be due to polyuria, ie producing more than 40 ml of urine per kg body
Primary RenaI werght per day. Causes o{ polyuria may be attributed to poorly controlled diabetes mellitus, diabetes
poLydipsia co nce ntra tin g
insipidus (Dl), primary polydipsia or poor renal concentrating capacity (nephrogenic Dl). The optimal
Look for urotogicaI treatment of each condition is specialised and bevond the intention of this article.
capacity text
causeS:
. prostatic obstruction HOW SHOULD ITREAT PATIENTS WITH NOCTURIA?
. nocturnaI detrusor Behavioial changes
ove ra ctivity A reduction in consumption oI caffeinated beverages such as cof{ee or tea at night and a reduction in
. neurogenic btadder water consumplion 2 hours before bedtime helps to decrease nocturnal diuresis. The eievation of lower
. parmacotogic limbs and using undergarments with graduated compression help to mobilise peripheral fluid to reduce
ag e nts Dx centraI Dx nephrogenic diuresis at night in the supine position.
. bLadder/ureteric diabetes diabetes
calcu Ii insipidus insipidus Medical therapy
Usage of sleep medications may be iridicated especially if the nocturia occurs as a result of poor sleep
Excessive PM or insomnia.
Chronic renal
ftuid intake faiture, [ithium,
Usage of diuretics in the presence of peripheral edema may help alleviate the situation. Commonly
tetracyc Ii ne,
0 bstru ctive {urosemide is used in the mid afternoon, to clear the fluid accumulated through the day. However, they
hyperca [ce n ia
s[eep apnoea should not be taken in the late evening, otherwise. the late onset of diurasis worsens nocturnal polyuria.
hypokalemia
su spected However, this regime is frequently difficult to manage as the individual rate of absorption of frusemide is
Isn ori ng, unpredictable.
obesity,
short neck) Specific treatment of nocturnal polyuria is the use of desmopressin (5), which is a synthetic analogue of
AVP This is a selective V2 (vassopressin) receptor agonjst with less uterotonic effects. Several randomized
controlled trials have shown good efficacy of desmopressin on nocturia. The main effect is to reduce
the urine output by water reabsorption, hence reducing the need to void. This in turn improves the
Abbreviations: NBC - nocturnal blabber capacity; NBCi - nocturnal blabber capacity index; time to first void and quality of life. Potentially serious side effect of hyponatraemia results Irom serum
NPi - noctunal polyuria index; MW = Maximum voided volume; mOsm/kg = osmolality dilution o{ sodium. Hence desmopre;sin is currently not indicated for patients more than 65 years. lt is
GBC - global bladder capacity recommended that sodium levels be taken at baseline, and soon after starting treatnrent, and regularly
thereafter. Patients should be educated on symptoms and signs of hyponatraemia and instructed to stop
Source: The New England Research institutes, lnc. (NERI) Nocturia advisory conference 201 2:focus on the medication rf that occurs.
outcomes of therapy. BJU lnt 2013 (4)

20 AN AppRoACH To coMMoN uRotoctcAt- DlsoRDERs I aN AppRoACH To NocruRtA AN APPROACH TO NOCTUiIA I AN APPROACH TO COMMON UROTOGICAT Di9ORDERS 21
 other medical therapies suitable for treatment at primary health
level also includes treatment with AN APPROAGH TO NOGIURIA: A FAMILV PHY$ICIAN'S
both day and niqht, ie
,ntiit,otin"rgl.r. This is useful for patients with problems of urinary frequency PERSPE TIUE
overactive bladder.
Dr Tan Hsien Yung David
people of both gender and all ages .
ln summary, nocturia is a common condition that occurs in Family Physician.Assoc,ate Consultant & Deputy Head, Jurong Polyclinic
the Various causes of
Management stems on patient,s bladder diary, which helps to differenliate Ass,stanf Director, Family Medicine Development Division,
with
no.triu. Due to the multifactorial causes, diiease pattern differentiation and co-management National Healthcare Group Polyclinics
the primary care physician allows streamlininq of management
Nocturia is a common cause of sleep distr,rrbance amongst the adult population witlr a rising prevalence
REFERENCES with age. lt usually affects more females in the younger age group, but the prevalence in men catches
,1'VanKerrebroeck,PAbrams,PChaikineta|.TheStandardisationofterminologyinnocturia: up in older age groups.

report from standardisation sull-committee of the international continence

societyNeurotlrol
With incidence rates of nocturia as high as 50 to 70% of older adults, it is not uncommon
Urodyn 2002; 21. 179-83.
for Family Physicians to encounter this symptom in the primary care setting. Thts may constitute a
2.BoschJL,Welss.lPTheprevalenceandcausesofnocturialurol20l0;184:440-6 Reason for Encounter, or as a "By the way" complaint. Regardless of the presentation, a thorough
results fron] the 3rd
3. V KUpelian, MP Fitzgerald et a|. Association of nocturia and mortality: history and relevant physical examination should be taken to determine the likely cause of the patients
national health and nutrition examination survey J Urol 2o11 185:571-1 ' clinical problem, gurde relevant investigations and suggest optimal management.
institutes, lnc. (NER!) Nocturia advisory
4. J Pweiss. J Blaivas, M Blanker et al. The New England Research
on outcomes of therapy BJU Int 201 3 Using John Murtagh's safe diagnostic strategy as a framework, some possible differentials of
conference 201 2: focus
5.VanKerrebroeck,ResapourM,CortesseAetal.Desmopressininttletreatmentofnocturia:a nocturia can be divided into the following:
double-blind, placebo-controlled study. Eur urol 2007; 57:221-9
Probable diagnosis: Prostatic Obstruction, Detrusor Overactivity, Excessive fluid intake, Alcohol/
Caffeine, Diabetes Mellitus

Red flags not to be missed: Chronic renal failure, Congestive Cardiac Failure, Liver Failure, Prostate/
Bladder Cancer

often missed (pitfalls): Drugs, Diabetes lnsipidus, obsiructive Sleep Apnoea, Urinary Retention,
Calcuii/Cystitis

Masquerades: Depression, Diabetes, Druqs, Endocrine disorders, Spinal dysfunction (neuroqenic

bladder), Unnary Trdci Iniection

ls the Patient Telling me something? (yellow flags) Insomnia, Depression

lnvestigations that can be perfonned in the primary care setting include urine analysis, and ascertaining
serurn electrolytes,creatinine, blood glucose and prostate specific antigen levels (if clinically relevant). A
bladder diary while inconvenient. may be of value if the patient is compliant and motivated.

Once serious conditions have been excluded, a trial of behavioural change or medical therapy as
previously described niay be initiated and the patient closely followed up {or response to treatment. lf
there is no improvement over a reasonable amount of time, the &tient should be referred to a specialist
for further evaluation.

AN APPROACH TO NOGURIA I AN APPROACH TO COMMON UROIOGICAL DISORDERS 23

AN APPROACH TO NOCTURIA
::, 22 AN APPROACH TO COMMON UROLOGICAI DISORDERS I
 Total incontinence
5 AN APPROAGH TO URINARY INCONTINENCE This refersto a continuous leakage of urine throughout the day and night. lt is due to a fistula between
the urinary tract and adjacent structures, thereby leading to urine bypassing the urethral sphincter. These
DrValerie Gan Huei Li conditions include vesicovaginal, ureterovaginal, or colovesical fistulae. ln less developed countries.
Registrar, Deparlment of lJrology, Singapore General Hospital
the primary cause is usually traumatic vaginal deliveries. Locally, these are usually iatrogenic (surgical
Dr Ng Lay Guat intervention or post pelvic radiation).
Head of Department and Senior Consultant, Depaftment of Urology,
Singapore General Hos?ital Some patients. especially the elderly, may have transient urinary incontinence that is not directly related
to any urological cause mentioned above. An easy way to remember the cause of transient incontinence
WHAT IS URINARY INCONTINENCE? is by the mnemoni( DIAPPER5:
D elirum
Urinary incontinence is an under-diagnosed and Under-reported problem as many patient5 are too
embarrassed to discuss their condition. They may also have the misconception that it is a normal I nfection of the urinary tract
aspect of ageing. lts prevalence is reported to be between 5 to 69olo in women and 1 to 39Yo in A trophic vaginitis
men. nlthough its prevalence increases with age, it is more common in women than in men by 2Jold P harmacological
at any age group. P sychological
$
E xcessive urine output (e.9. nocturnal polyuria, diabetes insipidus)
WHAT ARE THE DIFFERENT TYPES OF UR]NARY INCONTINEI{CE? R estricted mobility
Urge urinary incontinence (UUl) S tool impaction
UUJ is the involuntary loss of urine accompanied by or irnmediately preceded by a'strong desire to
void (urgency). This may be caused by detrusor over-activity (DO) on urodynamic study (UDS) or may
HOW SHOULD WE ASSESS PATIENTS WITH URINARY INCONTINENCE?
be purely sensory (i.e. no Do accompanying urgency on UDS).
History
Stress urinary incontinence (SUl) As for any medical assessment, a thorough history taking is of paramount importance in distinguishing
sUl is definerJ as the involuntary loss of urine when intravesical pressure exceeds the maximum between the drfferent types of urinary incontjnence. This should include the following:
urethral pressure in the absence of detrusor activity. Patients typically complain of involuntarv urinarV 1. Details of incontinence symptoms: seventy, quantity, need for padsr'diapers, aggravating/
leakage with activities that increase intra abdon-rinal pressure: e.g. coughing. laughing or sneezing. precipitating factors or events
This may be contributed by urethral hypermobility, bladder neck descent (with pelvic organ prolapse) 2. Associated storage/voiding symptoms: urgency, frequency, drvsuria, nocturia, suprapubic parn,
or intrinsic sphincter deficiency. Risk factors include obesity, multlple vaginal deliveries. assisted hematuria
deliveries (e.9. with forceps) 3. Concomitant bowel incontinence or pelvic organ prolapse
and menopause. 4. History of urinary tract infections

Mixed urinary incontinence

5. obstetric history
Some patients have symptoms suggestive of both SUI and UUl. lt is important to accurately diagnose
6. Surgical or radiation history
these patients and assess the severity of each component of incontinence /. Neurologicalhistory
8. Lifestyle history: Diet, exercise, caffeine/alcohol intake and smoking/Crug history
overflow incontinence 9. Medications e.g. druretics. cholinergics or anticholinergics
ln chronic urinary retention. when the bladder is full beyond its maximal capacity and the intravesical '10. Effect on daily activities and quality of life
pressure exceeds that of urethral resistance, urinary leakage occurs. This usually occurs in detrusor
failure, such as those with diabetic cystopathy or in patients with neurogenic/spinal injuries. These
Besides diagnosing the types of urinary incontinence, the aim of history taking is also to rule out
patients may not sense their full bladders and complain of frequent passage of small amounts of urine.
transient incontinence and the presence of any urinary stones or urothelial tract malignancies.
They may be mistakenly treated for UUI if not assessed properly.

Physical examination
1. General appearance: Body mass index
2. Abdominalexamination
3. Vaginal examination: atrophic vaginitis, presence of cystocoele/urethrocoele,/rectocoele. pelvic floor
sirength assessment using the Oxford scale, Q-tip test to look for urethral hypermobility, cough test
(supine and standing) to demonstrate 5UI
4. Digital rectal examination: prostate size and consistency, rectal masses, anal tone
5. Consider neurological examination especially in overflow incontinence or suspicion o{ spinal disorder

24 AN APPRoACH To coMMoN UROLoGICAL DISoRDERS I AN APPROACH TO URINARY INCONTINENCT AN APPROACH TO URINARY INCONTINENCT IAN APPROACH TOCOMMON UROTOGICAL DIsORDERS 25
 ti

lnvestigations AN APPMOAGH TO URINARY INGONTINENCE: A FAMILY

1. Urine dipstick / culture to look for signs of infection
PHYSIGIAIiI'S PERSPECTNE
2. Consider x-ray KUB to look for bladder/urethral stones if symptoms are suggestive
post-
3. An ultrasound scan to look for bladder lesionVstones, prostate sizelgrade and to assess Dr Matthew Ng Joo Ming
void residual urine. lt can also assesses for the presence o{ hydronephrosis in patients with Consultant, FMCC, Singapore General Hospital
overflow incontinence secondary to chronic urinary retention Head of Medical Services, Bright Vision Hospital
4. A voiding diary that spans three consecutive days. This charts intake/output volume, frequency,
types of iluids taken. tt also records associated symptoms like urgency, incontinence
episodes INTRODUCTION
and nocturia. Urinary incontinence is a common problem. lt used to be taboo and not commonly mentioned during
5. Blood investigations should include a renal panel if there is suspicion of renal impairment consultations rn the clinic; however this is changing with education and increasing awareness. The
secondary to obstructive uropathy manifesting as overflow incontinen'e prevalence of urinary incontinence increases with age and it affects the quality of life of both men and
women. The jnitial evaluation can be done in the family physician clinic with a two-step processl.
WHATARETHETREATMENTOPTIONSFORURINARYINCONTINENCE?
As the patients primary care provider, simple treatment can be instituted in
your clinic' Step 'l: ldentify and treat possible reversible causes
1. Lifestyle changes The mnemonic DIAPPERS is useful as an aid for recalling the common reversible causes of urinary
. incontinence. Family physicrans should also review patients medications especially those that have been
Weight reduction
started [ecently. Medication-induced incontinence can often be reversed by stopping the offending
. Decreasedfluid/caffeine/alcoholintake
medication.
. pelvic floor (Kegel) exercises: primary treatment in SUl, but improves symptoms in UUI as well'
This may be done with or without adjuncts such as vagirlal cones, biofeedback and electrical Step 2: Determine the type of incontinence (urge, stress, overflow, mixed, or functional)
stimulation The type of urinary incontinence can be determined using several questionnaires. The 3 lncontinence
. Bladder training: primary treatment for overactive bladder/UUl Questions is one such questionnaire available free of charge on the World Wide Web2. A
(timed voiding. voiding deierment) comprehensive medical history should be obtained with particular emphasis on prior bowel, back,
2. PharmacotheraPY: gynaecological or bladder surgery that could affect the anatomy and innervation of the lower urinary
. Antibiotics: lf there is eviclence of a urinary tract infection, it is prudent to follow up with a tract leading to incontinence.
repeat urine culture to ensure that the infection has cleared. one should reassess symptoms
after clearance of UTl. A physical examination is performed to iderrtify anatomic abnormalities or transient causes that may
. UUI: antimuscarinics (e.g. oxybutynin, toltelodine, solifenatin) help with alleviating
symptoms not have been considered after applyinq the DIAPPERS mnemonic. ln particular, the cardiovascular
examinations for evidence of fluid overload abdominal examination for masses and respiratory
of uul. Common side effects include dry eyevmouth and conslipation. Local vaginal oestrogen
examination for COPD. ln men, a digital rectal examination will identify prostate enlargement. ln women
therapy may also help to improve syillptoms of urogenital atrophy'
ol a pehric examination followed by a cough stress test will demonstrate atrophic vaginilis, pelvic organ
. SUI: duloxetine (selective serotonin reuptake inhibitot ssRl). There is a high rate
prolapse and stress incontinence respectively3. The digital rectal examination ls useful to assess for fecal
discontinuation due to nausea as a side effect. jmpaction that can exert pressure on the urethra and impair bladder emptying

WHEN WOULD YOU REFER YOUR PATIENT WITH URINARY Urea, electrolytes, creatinine, glucose and urinalysis are simple laboratory investigations that can be
INCONTINENCE TO AN UROLOGIST? performed in the clinic. Creatinine level may be elevated if there is urinary retention secondary to
When an underlying urological disease is suspected bladder outlet obstruction or denervation of the detrusor Urinalysis should be obtained to rule out
lf the patient has stones, especially if it is causing urinary tract obstruction, a
referral should be made'
haematuria, proteinuria, glycosuria and infection. lf a bladder scanner is available a PVRU should be
inu pu,i.nt should also Ue ieferred {or a cystoscopy or further imaging if malignancy is suspected. obtained. A PVRU of greater than 200m1 is suggestive of overflow as a main contributing cause of the
treated in tanderr witlt
Coniplex infections e.g. tuberculosis of the genitourinary tract should also be incontinence.
pyuria.
an iniectious disease physician. This may be suspected if the patient has sterile
@

REFERRAL FOR FURTHER EVALUATION

When a definitive diagnosis cannot be made
investigations e g an Referral to an urologist or urogynaecologist is recommended if the cause is unclear or the inconttnence
sorne patients may have mixed incontinence symptoms. They may need further js associated with recurrent urinary tract infections, new onset of neurological symptoms and pelvic
urodynamic study to accurately diagnose the problem'
organ prolapse. Patients with stress incontinence or urge incontinence with red-flags of haematuria,
obstructive symptoms and persistent proteinuria should be referred for further evaluation.
When first line treatment fails
lf first line treatment i.e. lifestyle changes and pharmacotherapy does not improve
the patients
symptoms, he/she may need 2nd or 3rd line treatment by the Urologist' REFERENCES
'1. Khandelwal C et al. Diagnosis of urinary lncontinence. Am Fam Physician. 2013;87(8):543-550
UUI) or surgery (e.9.
These include minimally invasive therapy (e.g. intra-detrusor Botox iniections for
2. Browrr J5 et al. Diagnostic aspects of incontinence Study Research group. The sensitivity and
tension-free vaginal tape for SUI).
specifiiity ui d simplc test to distinguish between urge and stress urinary incontinence. Ann lntern
Med. 2006;144(1 0):7 15-723
3. Hersh L et al. Clinical Management of Urinary lncontinence in Women. Am Fam Physician.
201 3;87(9):634-640

AN APPROACH TO URINARY INCONTINENCE I AN APPROACH TO COMMON UROLOGICAL DISORDERS 27

] 26 AN APPROACI1 TO COVIMON UROLOGICAL DISORDERS I AN APPROACH TO URINARY INCONTINENCE
 6 AN APPROACH TO ASYMPIOMATIG MIGROSGOPIG to renal impairment: lonq-standing-cliabetes mellitus, hypertensjon). On the other hand, a urological
assessment may be more rerevant rf: there
is absence oi p"ruautarr.rggestive of primary
HAEMAIT.IR|A (AMH) as stated above: i.e. absence of protejnuria, predominani renai disease
isomorphic Rgts; ana the presince ot risk
factors for urological disease or malignancy:
John Yuen Shyi Peng a) Smoking history
Senior Consultant, Depaftment of Urology, Singapore General Hospital
b) Age > 50 years

WHO NEEDS A FULL UROLOGICAL WORK.UP? c) Previous urological diseases

d) History of gross haematuria
Epidemiological studies have shown that the prevalence of asymptomatic microscopic haematuria
(AMH) is between 0.19 to 16.1% (1). However. heterogenity in detection methodology and e) H jstory of irritative voiding symptoms

population profiles in these studies result in wide-range prevalence of AMH. The widespread f) History of pelvic irradiation
diagnostic screening for microscopic haematuria at primary healthcare settings has resulted in large g) History of occupational exposure to chemicals or
dyes
number of patients re{erred to tertiary institutions for further evaluation. (benzenes or aromatic amines)

HOW IS MICROSCOPIC HAEMATURIA DEFINED? W_!AT DO UROLOGISTS DO FOR TI-IE EVALUATION OF PATIENTS
REFERRED WITI-I MH?
Microscopic haematuria 6VH) is d"iinud as the presence of three or more red blood cells (>3 RBC) per
high-power field (HPF) in a fresh and properly collected mid-stream urine sample under microscopic We are guided by the American LJrological Association (AUA) gujdeline on the evaluation
AMH (3) However. the optlmal evaluaiion of these patients of patients with
examinatron (2), (3). is controversjal. This is reflected by ,Lhe fact
However. the caveats are: that out of the I 9 statements on the AUA guideline,
t 1 werl ,ecommendations basecj on evidence
grade C, whire the remaining 8 statements
i. MH is detected by urinary microscopy, and not by a dipstick test that detects heme, thus grving were based on either expert
irincipte.: rn
rise to false positive results in the presence o{ myoglobinuria or haemoglobinuna
singapore' we are also guided on this aspect
by the lvrinistrf of t leaith clinical "-i"i.ig;ijetiner
"piri""practice
ana
our local experience on the evaluation patients'with '
' ii. The urine specimen should be freshly collected as {ormed elements (such as cells and casts)
AMH.
degenerate and bacteria may overgrow at room temperature suffice to, say tl rat the urological assessment o1 lr,4H
rnvolves a detailed history, physical exanlination
iii. The urine specimen should be a clean catch, mid-stream urine sample, so that contarrirratiorr follonred by imaginq evaluation oi the upper (kidn"y,
ur"t.o) and lower (bladder and urethra)
the "na
by skin, vaqinal cells, bacteria arrd protein-containinq secretions is minimised. urinary lracts However, most patients referred for
evaluation of AIvIH has incomplete or inadequate
primary evaluation that may require
the urorogists to ,"qr.riio, UFEME or upc. The
subsequent urological evaluations depends on-risk comprexity of
IS SOME DEGREE OF MH CONSIDERED NORMAL? stratlircaiion of patients for urological disease.
primary aim is to exclude urological malignancies, The
in partiiular urothelial malignancy. For patients
of Mll is normal. such that 1-J
The above definition implies that some deqree RBC/HPF on low risk factors for urorogical disease with
.
1ag-e so vur", non-*oker, no history of gross haematuria,
microscopic examination is considered acceptable. urological disease or symptoms) an upper urinary
tract irnaginq witn an ultrasound kidneys and bladder.
a KUB.x-ray to detect urinary stone, with or without
urinar/cyiology are sufficient to rule out seriolrs
I5 SCREENING FOR MH RECOMMENDED? urological underlying causes in most cases. For patients
wiih risk factors for urological disease (age >
Routine screening of asymptomatic population for MH is not recommended (Clinical Practice 50 years, high RBC count on UFEME, smoker, hLtory
of painress gross haematurial irrrtative urologicar
Guidelines on Glomerulonephritis, Ministry of Health 5ingapore ZOOT ,2 The US Preventive Services symp-toms). an upper urinary tract imaging of
highei sensitivity i.e. cr urography wi*, conirasi totto*
by a flexible cystoscopy examination miy be
Task Force,4 The Canadian Task Force on the Periodic Health Examination5). However, our MOH wairanted. rt is sJirice to ruyir,ui., ir-.,"r" i"r.r,iqr,,""r.*
costly arrd not entirely risk{ree (radiological contrast
guideline states that dipstick examination is recommended for those who are at risk for renal diseases ,"y oe nepr,rotoxrc and may cause allergic reaction),
for the purposes of detectrng proteinuria or AMH.(2) and rather invasive (frexible cystoscopy), orrry serect patrents
wiiir nigh", ,ir[iu.i;, i", i,n",iL*
urologrcal disease or marignancy undergo cr
urography and frexibre cystoscopy in our centre.
especially so for indication of frexibre cystoscopy This is
IF MH 15 DETECTED, IS 1T ALWAYS CLINICALLY SIGNIFICANT? us ti,eir,unc" of finding any urorogicar
abnormarity is
low when this is performed for the indlcation
MH is probably not clinically significant, if the diagnostic test was carried out during or soon after:
oi AMH.
menstruation, vigorous exercise, sexual activity. viral illness, trauma, infections (i.e. recent UTI) WHAT ARE THE CHANCES OF FINDING UROTHELIAL
or recent urological instrumentation. Under these circumstances, one is recommended to repeat MATIGNANCY ON
FLEXIBLE CYST'OSCOPY FOR MH?
an UFEME (urine full examination and microscopic examination) in a {ew weeks' time following
appropriate treatment, e.g. treatment oI UTl. As alluded to above, it is common practice in
Urology centre that only patients with known
for r:rologicar disease were sereded to unaerqo risk factors
fle;bte ;rior.opy. Thus, 85% of patients who undergo
I NEED TO REFER PATIENTS WITH AMH TO HOSPITAL, WHICH SPECIALTY flexiblecystoscopyinurologycentreareolde"rthansov"r."ro
lnaretrospectivestudyof .1200 1exible
(NEPHROLOGY OR UROLOGY) SHOULD THE PATIENT BE REFERRED TO? cystoscopy performed for the evar.uation of AMH
after negative upper tract imaging over a 1g-year
period in the Urotoqy Centre, 90.i%
This would depend on one's clinical suspicion o{ whether the cause of MH is a medical (e.9.
of the cystoscopy
0 6% of patients were found to have urotheriar
fi"i;;q;;.r; .;;ii;;;;i;;;Jd;). o"t,
glomerulonephritis) or a surgical (e.9. urinary stone, malignancy) one; please refer to AMH Evaluation ,urignun.f ot'ir," bradder. of those with abnormar
findings (- 9% of totar cohort) had benign
Algorithm below. One can infer Irom the parameters in the UFEME, urine phase contrast (uPC) and cautes iniruJingiysrtis, sma, urinary stones). we
conclude that the yield of flexible cystoscopy can
clinical factors in order to decide whom the patients should be referred to. in detecting ,"orogi.ur malignancies in patients
the,evaluation of AMH is very row. Therefore, referred for
malignancies such as bradder cancer. rn fact.
,.ru"ninf il. arrrH is not a usefur way to detect urotherial
screening for trrrH has not been shown to have
ln general, patients should ideally be evaluated by a nephrologist if; uFEME shows significant on the overall prognosis of patients with urothelial any impact
proteinuria; uPC shows dysmorphic RBC and red cell casts; and there are sign:, of renal impairment caicer (o), (7), (8). Most bladder cancers detected in
the urology clinic are superficiar cancers and have good
and an elevated serum creatinine level (patients with renal impairment or risk factors predisposing a progn*o in the absence of screening.
AN APPROACH TO COMMON UROLOGICAT DISORDERS I AN APPROACH TO ASYMPTOMATIC MICROSCOPIC HAIMATURiA (AMH) aN aPPRoAcH To ASYMPTOMATI. MlcRoscoPlc
HAEMATuRIa (AMH) I AN APPRoA.H ro coMMoN u,olocrcAt DrsoRDeRs 29
 AMH EVALUATION ALGORITHM
TAKE HOME MESSAGES:
a) MHisdefinedasthepresenceot>3RBC/HPFundermicroscopy.Thus,somedegreeofMH(1-3
RBC/HPF) is considered normal.
b) MH is detected by urinary microscopy, not dipstick'
c) AMH is common.
is essential'
d) Fresh, properly collected mid-stream urinary specimen
or soon after: menstruation' vigorous exercise'
e) Repeat uFEME i{ urine specimen collected during
sexual activity, viral illness, trauma, infection(i
e recent UTI)'
is not recommended'
f) Screening of asymptomatic population for MH lnitiaI assessment by
history & physicaL
9)Referraltonephrologistsisindicatedifthereispresenceof:proteinuria'dysmorphicRBCorred
cell cast, renal lmPdilment' examination for other
by
The detection of urclogical malignancy a{ter full
urologicalevatuations including upper imaging potentiaI causes [e.g.
h)
aniti"'iUt" tyttottopy is iow for AMH The complexity of
urological
ultrasound or Ct urograpny Repeat UFEME after i nfecti on,
should be calibrated according to
investigations by CT imaging and / or flextle cystoscopy treatment of other menstruation, recent
pattent's rlsk factors for urological malignancy' cause{s) e.g. infection urologicaI procedures,
*Type of imaging
for MH is not a recommended screening test for urothelial
malignancies'
i) Screening trauma, viraI ittness,
sexuaI activityl depends on c[inicaI
REFERENCES suspicion of
of asymptoma[ic adults {or urinary tract underlying urotogicaI
1. Woolhandler S et al. Dipsilck urinalysis screenlng No further conditions and risk
disorders. l. Hematuria and proteinuria JAMA 1989;262:1214-9'
Glomerulonephritls 2007' investigation factors (e.g. history
2. Ministry of Health, Singapore Clinical Practice Guidelines - PotentiaI renaI causes
{ollow-up of asymptomatic microhaematuria (AMH) in Ie.9. significant of smoking, gross
3. Davis R et al. Diagnosis, evaluation and
haematuria, age>50,
adults: AUA guideline. 2012' proteinu ria,
preventive service Task Force. Guide to clinical preventive services: report of
the us Prevelltive Evaluation for dysmorphic RBC or irritative voiding
4. primary renaI disease symptoms, chemicaI
& Wilkins' 1'096
Services Task Force. 2nd ed Baltimore: Williams cet[ casts, elevated
serum creatinine) exposu re)
5.CanadianTaskForceonthcPeriodicHealthEramination.c.anadianguidetoclinicalpreventive
health care. Ottawa: Canada Communication
Group' 1994:826-36'
** lfCT urogram is
6.Messing,EMetal.Homescreeningforhematuria:resultsofamulti-clinicstudy.JUrol,l992;
contra-indicated,
148:289-97.
screening by the detection of occult consider MR
7. Britton Jp et al. A community study of bladder cancer Urotogical evaluation*
Urol 1992; 148:788-90' urogfam, or
urinary bleeding. J
- Upper urinary tract
outcome in men underqoing hematuria home retrograde
8. Messing EM et al comparison of bladder cancer imaging by uttrasound pyetogram in
screeningverSusthosewlthstandardclinicalpresentations.Urologylgg5;45..387-97. kidney/btadder, KUB combination with
x-ray, CT urogram *+ non-contrast CT KUB
- Cystoscopy OT US
Foltow up as indicated
by diagnosis. Fottow persistent
Re-eva[uate for MH Fottow up with at AMH with annuaI
after resolution of least one uFEME UFEME. Refer for
identified condition yearly for at least two nephrotogic
years evatuation if
indicated. Repeat
urotogicaI evatuaiion
Discharge from fottow up
within 3 to 5 years if
c[inicalty indicated
especialty in high-risk
individuats

Adaptedlrom MinisoT of Health Singaporc, Clinical Practice Guidelines on

Glomerulonephritis 2007: and AUA Guideline on Asymplonatic Microhaematuria 2012.

AN APPROACH TO ASYMPTOMATIC MICROSCOPIC HAEMATURIA (AMH) I AN APPROACI] TO COMMON UROLOGICAL DISORDERS 31

AN APPROACH TO ASYMPTOMATIC MICROSCOPIC HAEMATURIA (AMH)
rl
.I
so AN APPROACH TO COMMON UROLOGICAL DISORD€Rs
I
 AN APPROAGH T0 MIGR0SC0PIG HAEMAIURIA: A FAMILY 7 AI'I APPROAGI{ TO_ ASYMPTOMATIC PYURIA
PHYSIGIAN'S PERSPEGTIUE Dr Ng Lay Guat
Head of Depaftment and Senior Consultant, Depaftment of Urology,
Dr Juliana Bahadin Singapole General HosOitll
Director & Consultant Family Physician, SingHealth Polyclinics- Bedok
,r,".,
,,r.; ;;;":;;;;, ;; .;
""; *" ;;;r"; ;;r;,"-,
This is not a chapter to a,r.r., ;; 0""0,
Patients with microscopic haematuria (AMH) typically present to the family physician after health I have clrosen to discuss a commonly encountered situation. ',
which rs often mismanaged
screening or for evaluation of urinary disorders such as pain during urination, frequent urinatton, - asiimptomatic pyuria.
suprapubic pain or loin-to-groin pain. For asymptomatic patients, evaluation of the incidental
findings of AMH has to be focused on excluding red-flags like urological tract carcinomas and Pyuria is a condition whereby a large number of white blood cells are detected in the urine. This
glomeiulonephritis. For symptomatic patients, careful history taking can help to identify the
rs
usually noted either on dipstick or on urinalysis. ln an asymptomatic patient, the most important
iauses of AMH. History taking would include presence of urinary symptoms, recent menstruation, first step is to repeat the test, preferably with a microscopic urinalysis, in order to ensure lhere is no
vigorous exercise, recent sexual activity, trauma, recent infections (such as those of the urinary contamination during urine sample collection
tract, upper respiratory tract or intestinal tract) or recent urological instrumentation. ln addition.
history of systemic illneSses are also important such as: hypertension, autoimmune disease, bleeding Standard urinalysis reports the presence of red blood cells, white blood cells, and other components.
disorders or systemic syrfrptoms such as weight loss, loss of appetite, {ever, rashes,
joint pain or the
The presence oi epithelial cells is reported when the technician detects spindle shaped cells in the
consumption of any antiplatelet or anticoagulation drugs and TCM consumptlon' specimen. The most ccmmon spindle shaped cells rn this case are skin cells, i.e. squanrous cells.

Physical examination should include ihe assessment for pallor, blood pressure measurement, an
abdominal examination and a per rectal examination if prostate enlargement is suspected. ln women,
especially where the history is ambiguous, per vaginal examination should be performed to exclude
gynaecological abnormalities. A urine culture is useful if there is suspicion of a urinary tract infection.
Oiher investiqations include urine phase contrast microscopy, protein creatinine ratio, renal function
test (potassium. urea and creatlnine levels) and a full blood count.
Contamination with vaginal secretions and vaginal skin is a very common occurrence, particularly in
female, elderly patrents. This is especially common if the patient is heavy built and has a very deep
introitus. The usual mid-stream urine is inadequate in reducing this contaminatron. We recommend that
a clean catch, mid- stream urine be collected after vaginal cleansing with wet cotton, and with the labia
minora parted, as seen in the diagram below. When this repeat specimen shows persistent WBC5 with
minimal epithelial cel!s. one should be obliged to investigate the patient.

patients with signs of glomerulonephritis, (hyperterrsion. presence of significant proteinuria, abncrmal

renal {unction test and dysmorphic red blood cells on urine phase contrast microscopy), should be
referred to a nephrologist, while patients without the above symptoms are usually referred to an
urologist. pati€nts with severe proteinuria and uilcontrolled hypertension should be given an early
i..1,
ti
{; i,-'r
lr i t"
t:_
\l i

appohtment to see a nephrologist. Simiiarly. if patients have symptoms and signs suggestive 01
.&ir
malignancy such as anaemia, loss of weight, loss of appetite and abdominal mass should be given an
and
tj,'f
early appointment to see an urologist. These patients would be counselled for possible diagnoses '\'*ri
pr"-urpt"d on possible investigations and management by the specialist. Also, patients' expectations
and anxiety would be managed accordingly.

Last, but not least, patients would also be advised that they can return to constrlt their Family
Physicians to clarify any concerns that they might have even after they have consulted the specialists.

Figurel. Sitling position for clean catch Figure 2 Parting the labia, and cleaning the meatus with wet
midstream urine cotton. The mid-stream urine sample is collected withoul
letting the labia re-appose.

,2 AN APPROACH TO COMMON UROLOGICAL DISORDERs I AN APPROACH TO ASYMPTOMATIC MICRO9COPIC HAGMATURIA (AMH) AN APPROACH IO ASYMPTOMATIC PYUEIA IANAPPROACHTOCOMMONUROLOGICALDISORDERS 33
 of these wBCs Pyuria Once physiological and in{ective causes are excluded, other significant pathologies may also cause
when the diagnosis pyuria rs established, it is important to evaluate the source
tn an asymptomatic patient, the diagnosis o{ asymptomatic pyuria. lmaging modalities such as intravenous urogram (lVU) or CT intravenous urogram
can exist with-or without the presence of bacteriuria.
the various conditions that can can be done to exclude upper tract obstruction, malignancies or calculus disease. Cystoscopy and urine
a-rimple lo*", urinary tract iniection is very unlikely. Table 1. shows
cylology will also be required to exclude bladder ClS.
cause the Presence of PYuria.

REFEREI{CES
Table 1. The causes of asymptomatic pyuria
1. Richard Colgan et al. American Family Physrcian, September 15, 2006,Volume 74, Number 6,
Asymptomatic Bacteriuria in Adults
Nidus of infection
2. Ouslander JG et al. J Am Geriatr soc. 1996 Apr;44(4):420-3. Pyuria among chronically incontinent
lndwetting but otherwise asymptomatic nursing home residents.
cathete r 3. van Vollenhoven P et al. Urol Res. 1996;24(7):1 07-1 1. Polymerase chain reaction ln the diagnosis
of urinary tract tuberculosis.

Bladder outtet ALGORITHM FOR APPROACH TO ASYMPTOMATIC PYURIA

PartiatLy treated
urinary tract obstru ctio n
i nfect ion causing high
post void Asymptomatic Pyuria
residual urine

PyuriaisexpectedinpatientsonlongtermindwellingcatheterandonpatientsWhoperformcle-an ^ I {
not imply infection ln fact,
internrittent self cathererization (Clse) (1). This is physiological and does lDC, CISC, partially Exclude contamination with Physical examination and
these cases, treatment is not routinely indicated in asymptomatic treated UTI clean catch mid slream urine
even when bacteria are identi{ied in PVRIJ assessment
resistancc to anti-microbial
individuals. Antibiotic therapy is more Iikely to promote baclerial
women or those planned for
treatment. However, active treatment is recotnnrended in pregnant
invasive urological Procedures.

m
The presence of mild pyuria in elderly females can be
physiological, as this is likely related to atrophic ,
females with underlying
urqi;ho in u port ,"nop.ural state iz). ln a study of nursing home resident Presence of cystocele or
a clean catch mid-stream urine sample showed the presence of asympLolrlatic
urinary inconiinence, urethral diverticulum
pyu,ialn+sv"oftheseindividualsWithoutclinicalevidenceclfalowerUrinarytractinfection.

Duringevaluation,adetaiIedphysicalexaminationistargetedtoidentifvanatomicaldisorderssuch
as cysioceles and urethral diverticuli in females. This is usually
evident on per-vaginal examination'
tn males, a prostate infection may yield tenderness on digital
rectal examination Post-void residual
bladder scan. An in-out catheterisation
urine volume (PVRU) can ue measurect by ultrasound or by a
are not available'
procedure can be done to quantify PVRU when ultrasound scans Teach patient to reduce
cystocele post void.
Thepresenceof'sterile'pyuriaoccurswhentheoffensivepathogencannotbeidentifiedontheusual lmaging / refer urology
culturemedium.TheCommonestcauseo{sterilepyuriaisthatoftuberculosis(TB)oftheurinary
rract. This can be asymptomatic if the kidneys are ihe ottly
urinary organ involved When tle bladder
is involved, the patient will usually have severe lower urinary tract symptoms. The investiqation of
void morning specimens for AFB smear and mycobacterium culture'
fhoice would be collection of firsi
polymerase chain reaction (PCR) is a
l-he latter generally takes 6 weeks to yield any results. The
whereby the presence of an
technrqueihat can be used to amplify a ,p".ifi. DNa gunomic sequence,
small number of bacteria can be detected. The high sensltivity of PCR is particularly useful in
extremlly
paucibacillary situations such as urinary TB (3)'

AN APPROACH TO ASYMPTOMATIC PYURIA AN APPROACH TO ASYMPTOMATIC PYURIA I AN APPROACH TO COMMON UROLOGICAL DISORDTRS 35
,i :c luleenolcrrTocoMMoNURoLoGlcALDlsoRDERsl
 AI'l APPR0ACH T0 ASYMPT0MATIC PYURIA AND liro[)lerns with treating asymptomatic pyuria include anti-mrcrobial resistance, exposing patients to
potential side ef{ects of antibiotics as well as the cost of treatment (3).
BAGTEBIURIA: A FAMIIY PHYSICIAN'S PERSPEGIIUE
The decision {or a referral to the urologist often hinges on factors such as the presence of urinary
Dr Koong Ying Leng Agnes symptoms, significant risk factors for urological malignancies such as smoking, as well as patients desire
Director & Family Physician, Consultant, to undertake {urther investigations. Patients may also be empowered with the knowledge of symptom
SingHealth Polyclinics-Mari ne P arade recognition requiring them to seek consultation when required.

Asymptomatic pyuria is commonly encountered in the primary care setting as urine analysis is used
REFERENCES
to screen for micro-vascular complications of common chronic conditions such as diabetes and
hypertension. Therefore, the diagnosis o{ pyuria is usually incidental. 1. Zhanel GG, Nicolle LE, Harding GM. Prevalence of asymptomatic bacteriuria and associatecl host
factors in women with diabetes mellitus. Manitoba Diabetic Urinary lnfection Study Group. Clin
Pyuria, in the absence of symptoms. is often a result of contamination in the urine collection process. lnfect Drs 1995;21 :31 6-22.
As mentioned an this chapter, it is commonly seen in the elderly females. Asymptomatic pyuria is also 2. Renko M. Tapanainen P Tossavainen P, Pokka T, Uhari l\4. Meta-analysis of the srgniflcance of
more prevalent in the diabetics (1,2). asymptomatic bacteriuria in diabeles. Diabetes Care 34:230-233,2O1 1
3. Nicolle LE, Bradley s. colgan R, Rice JC, Schaeffer A, Hooton TM. lnfectious Diseases Society of
When asymptomatic pyu?ia is associated with epithelial cell contamination, a repeat sample should America Guidelines for the dragnosis and treatment of asymptomatic bacteriuria in adults. Clin
be obtained. However, obtaining a mid stream sample can be challenging for many of our patients ln[ect Dis 2OO5:4O.643-54
in the polyclinic setting. Patients may have difficulty voiding adequate urtne volumes during at
4. Harding GKM, Zhanel GG, Nicolle LE, Cheang M. Antimicrobial treatment in dlabetic women with
the laboratory as they may have fasting requirements prior to blood tests. Other dif{iculties faced
asymptomatic bacteriuria. Manitoba Diabetes Urinary Tract lnfection Study Group. N Engl J Med
include patients with incontinence, or those on fluid restriction for medical indications. lt is also time
2002: 347:1 57 6-83
intensive {or the laboratory stafl to give detailed instructions on the appropriate way to collect mid-
stream urine, in the face of a high patrent load.

We do not routinely perform urine cultures on these specimens. as the result often does not affect
management of the patient. However, in the context of literature review on this topic, most studies
involve patients with asymptomatic bacteriuria, whrch ts defined as
. 2 consecutive voided urine specimens with rsolatron of the same bacterial strain rn quantitative
counts > 105cfu/ml.
. 'l
A single, clean-catch voided urine specimen with bacterial species isolated in a quantitative
count > 1Oscfu/ml in men.
. A singe catheterized urine specimen with 1 bacterial specres isolated in a quantitative count >
105cfu/ml in women or men (3).

Physicians should evaluate for underlying causes of asymptomatic pyuria through evaluation o{
symptoms suggestive of urinary tract infection such as dysuria, frequency, haematttria, lower
abdominal pain and fever. lt is important to also illicit symptoms suggestive of lower urinary tract
obstruction as well as renal calculi disease.

The lnfectious Diseases Society of America Guidelines recommends that routine treatment of patients
with asymptomatic bacteriuria is not indicated, unless they are pregnant, or undergoing urological
procedures such as transurethral resection of prostate or undergoing procedures where mucosal
bleeding in the urological system is anticipated (3).

There have been cross sectional studies mentioned in a meta-analysis o{ the significance of
asymptomatic bacteriuria in diabetics, showing an increased association with the subsequent
development of symptomatic urinary tract infection. There appeared 1o be no significant differences
in creatinine level and glomerular filtration rate in diabetics with or without asymptomatic
bacteriu(a [3] However, in a randomized, controlled double blind trial amongst diabetic women with
asymptomatic bacteriuria, with or without anti-microbial treatment, patients who did not received
anti-microbial therapy did not have an increased incidence of urinary tract infection compared to
the group who received anti-microbial therapy. Neither was there a significant difference in renal
complications such as pyelonephritis or increased hospitalization days (4).

35 AN APPRoACH To CoMMON UROLOGICAL DISORDTRS I AN APPROACH TO ASYMPTOMATIC PYURIA

AN APPROACH TO ASYMPTOMATIC PYURIA I AN APPROACH TO COMMON UROLOGICAL DI5ORDFRS 37
 ln other words. the PLCO study showed no benefit for PSA screening at 1 3 years, but the European
I AN APFRoACH T0 PRoSTATE SPEGIFIG At'lTlGEN (PSA) AND study showed rirodest benefit at 1 1 years. Upon closer scrutiny, the PLCO study was criticised for
irrcluding men with prior PSA testing in the control arm and a high proportion of men with elevated PSA
who did not comply with prostate biopsy. This statistical contamination and verification bias resulted in a
study comparing organised PSA screening against opportunistic screening that may have contributed to
Dr Sirn Hong Gee
Hospital the lack of difference in mortality rates. The European study had slightly different screening protocols
Senior Coniultant, Department of Urology, Singapore General in each country and higher treatment intensity for the screened arm. This may bias towards favourable

wnatri iHr inir,ro iN ilofi"il cartlcrn lNclDENcE? outcomes. Additionally, the study was thoughl to be more of a meta-analysis rather than a randomised
trial because of the varied screening protocols. However. the relative risk reduction in development of
prostate cancer is the third ntost common cancer in singaporean men. The tncidence is rising and
prostate cancer metastasis and cancer-specific mortality was consistent on extended follow-up and was
moremenarebeingdiagnosedatayoungerage.lnthetimeperiodfrom200gto20ll,theage- noted to be greatest in men between the age group of 55 and 69 years.
mortality rate was 54
standardised incidence rite was Ze.g p", tOO,OOO and the age-standardised
per 1 00,000. WHO WOULD BENEFIT FROM PSA TESTING?
(incidence) has increased from 94 cases in The main contemporary indications for PSA test rnclude
The number o1 newly diagnosed prostate cancer cases
the period 1g6a-1g72 toit88.ur., in the period 2003-2007.
The age-standardised incidence 1. follow-up after primary definitive treatment (surgery or radiation) for early,
't
rates have increased from 4.0 to 24.'l per 00,000
per year rn males during the same pericds The locally advanced and metastatic prostate cancer,
increased from 1 3 per 1 00'000 2.
age-standardised mortality rates for prostate cancer in males have prognostication of men diagnosed with prostate cancer,
peryearto+.7perto0,060pury"ui{ro*theperiod 1968-1972rotheperiod2003-2007witha 3. screening of high risk asymptomatic men,
decrease in the most recent period' 4. screening of men with lower urinary tract symptoms.
5. opportunistic screenrng of asymptomatic men between 55 to 69 years with
Comparatively,theproportionofmetastaticprostatecancerhasdeclinedoverthelasttwodecades
patients are diagnosed by transrectal ultrasound guided at least 1 0- l 5 years' life expectancy.
as a result of early detection with PSA. More
prostateneedlebiopsyaranearlierstage,Fewerpatientsarediagnosedbytransurethralresectionof
HiEh risk individuals include men with positive family history of prostate cancer and African-Americans.
prostate and bone biopsy.

ARE THERE ALTERNATIVE TE5T5 TO PSA IN DETECTION OF

WHATISTHERATIoNALEFoRPRoSTATEcANcERSCREENING? EARLY PROSTATE CANCER?
Early prostate cancer is curable but many cases present without
symptoms and are detectable only by
lower urinary tract There are PSA derivatives that may help to select men wlro may have a higher risk of high-grade
proitate specific antigen and digital rectal examirtation (DRE). Others present with
presents with local obstructive prostate cancer. These include high PSA velocity or kinetrcs (PSAV), high PSA-prostate volume density
,yapto,,-.,iand bladder outlet obstruction. Advance prostate canaer
occur ln a lrrlrd of these patients' (PSAD), hiqh PSA doubling time (PSADT or time to double PSA) and PSA intermediary n-retabolites
symptoms, as well as metastatic symptoms. Sketetal-related events (pro-PSA etc). However, patient counsolling and compliance are important in men considering these
andincludebonepain,patho|ogicaIf.,.tu,",oftheverlebraeandlongbones,hypercalcaemiaand derivative tests. Use of advance imaging modalities in lieu of histological diagnosis in men suspected of
cauda equina sYndrome.
early prostate cancer, including MRI (anatomic, functional, multi-parametric, whole body), CT-PET and
other metabolic imaging should be considered experimental.
WHATARETh{EPITFALLSOFPROSTATECANCERSCREET$ING?
There are valid concerns about over diagnosis, overtreatment,
and complicattons oi the diagnostic WHAT DO WE TELL PATIENTS WHO ASK FOR PSA TESTING?
prostate biopsy and treatment. This haito be balancecl against the risks of disease progression 1o
Based on the l\4tnistry of Health Singapore 2010 guidelines on prostate cancer early detection, routine
metastases, and the ccmplications of advance prostate cancer' population screening of asymptomatic men is not recommended.

WhIATDoTFIEPRoSTATEcANcERscREENINGTRIALSTELLUS? The American Urological Association 2013 guidelines do not recommend routine PSA screening of
any asymptomatic men below age 40 years, asymptomatic men rrJiih average risk between 40 and 54
Thereare2majorrandomisedprostatecancerscreeningtrialsWithinterimsurvivaloutcomes.The
years or above 70 years with less than 1 0-1 5 years' life expectancy. High risk men between 40-54 years
PLco(Prostate,Lung,Co|orectalandovariancancer)triallookedat76685men,aged55_74
years,rvhowereenrolledatl0sLreeninqCentersinUsAbetweenNovemberl993and]Uly2001 and men above 70 years with long life expectancy can be considered for PSA test. Between age 55
digital rectal examination) and and 69 years, counselling of risks of screening and overtreatment and shared decision-making for men
and randomly assigned to the interventi6n (psA testing and annual
considering PSA testing should be performed. Specifically, the benefit of preventing 1 mortality in 1 000
controlarms.afterl3yearsoffollow-up,theCumulativemortalityratesfromprostateCancerin
the intervention and control arms were 3.7 and 3.4 deaths
per 1 0 000 person-years, respectively, screened men over a decade needs to be werghed against the risks of over screening and overtreatment
resultinginanon.statisticallysignificantdifferencebetweenthetwoarms(RR=1.o9,95yoCl=0.87
cancer) trial looked at
to 1.36). The ERSPC (European"Randomized study of Screening for Prostate SUGGESTED ALGORITHM TOWARDS PsA TESTING
l82,l60menbetweentheagesof50andT4yearsenrolledineightEuropeancountriesbetween Patients with life expectan(y of less than 10 years
group, the relative reduction
19g5 and 2003. After a medln follow-up of 1 1 years in the core age
in the risk o{ death {rom prostate cancer in the screening
group was 21Yo (rat9 ratio' 0 79; 95% i. Asymptomatrc patient -> no role for PSA testrng
for noncompliance'
confidence interval [cl], 0.68 to 0.91; P = 0.001), and2gok after adjustment ii. Pre;ei rce o{ lower urinary tract symptoms (LUTS) or abnormal DRE -> consider PSA testing and
relative risk reduciion in the development of prostate cancer metastasis was 3070 (hazard ralio
The urological evaluation
[HR]: 0.70; 95% conficlence interval [ct]'
0 60-0 82; p = 0 001) To prevent one death from prostate
cancer at 1 i years of follow-up, 1 055 men would need to be invited
for screening and 37 cancers
would need to be detected. Tire resulting numbers needed to invite
for screening to avoid I case of
metastaticcliseasewas328,andlhenumbersneededtodiagnosewasl2.
ANAPPROACHTOPROSTATESPECITICANTIGEN(PSA)ANDPROSTATEONCERSCREENING IANAPPROACTITOCOMMONUROLOGICALDISORDERS 39
j3s I AN APPROACH TO PROSTATE SPECITIC ANTIGEN (PsA) AND PnOSTATE CANCER SCREENING
AN APPROACfl TO CONIMON UROLOGICAL DlsoRDERS
 PATIENTS WITH LIFE EXPECTANCY OF MORE THAN 1O YEARS PR0STATE CAilCER SGBEENING: THE FAMILY PllYSlGlAN,S
i. Asymptomatic patient - pros and cons of PSA testing (screening) needs to be discussed PERSPEGTIUE
ii. Presence of LUTS or abnormai DRE -> recommend PSA testing and urological evaluation
Dr Gilbert Tan
Director & Consultant Family Physician, SingHealth Polyclinics-Geylang
REFERENCES
1. National Registry of Diseases Office. Singapore Cancer Registry lnterim Annual Registry The family physician (FP) is often the first point of contact for patients requestinq for prostate cancer
Report:Trends in Cancer lnctdence in Singapore 2007-2011. Webpage http://www.nrdo.gov.sg screening. The approach of the FP should begin with exploring the ideas, concerns and expectations
accessed on 6 June 20'13. (lCE) of the patient with regards to prostate cancer screening. Patients often see all screening tests for
2. Andriole GL et al. Prostate Cancer Screeninq in the Randomized Prostate, Lung, Colorectal, and cancers as equally useful and effective. They may also have misconceptions about screening tests and
'13 Years of Follow-up. J Natl Cancer lnst
Ovarian Cancer Screening Trial: Mortality Results after their applicability. By obtaining the ICE o{ the patient, the doctor can provide patient-specific education
2012:104.125-132. and advice for or against prostate cancer screening. The patients age and health status should also be
3. SchrOder FH et aI.ERSPC Prostate-Cancer Mortality at 1 1 Years of Follow-up. N Engl J Med taken in consideration.
20'12; 366:981-90.
4. Schroder FH et al. lqreening for Prostate Cancer Decreases the Risk of Developing Metastatic The next task for the FP would be to assess if the patient is at high or low risk for prostate cancer. High
Disease: Findinqs from the European Randomized Study of Screening for Prostate Cancer risk includes patients with a strong positive family history of prostate cancer (diagnosed before 65 years
(ERSPC). Eur Urol 201 2; 62: 7 45-7 52. of age - father and/or brothe(s)). The FP should also check for presence of any siqnificant symptoms
such as lower urinary tract symptoms and bladder outlet obstruction. There is a role for screening
5. American Urological Association guidelines on early detection of prostate cdncer. Webpage
in those who are high risk or symptomatic. ln other clinical srtuations, the FP should assess clinical
http://www.auanet.orgleducation/guidefineyprostate-cancer-detection.cfm accessed on
rndicatlons for screening and ensure that the patient makes an informed-choice about the benefits
6 June 2013
versus harm of screeninE.

Screening at the primary care setting includes both digital rectal examination (DRE) and Prostate Specific
Antigen (PSA) testing. ln low risk, asymptomatic individuals, a normal DRE and PSA levels less than 4 ng/ml
is assuring. But rajsed PSA levels and/or abnormal DRE would mean a referral to the urologist for {urther
workup including possible invasive prostate biopsy. The abnormal screerring outcon.re also crcates a sense
of anxiety in patients that must also be addressed bV the FP

40 AN APPRoACH To coMMoN UnoToGIcAT DISoRDERS I AN APPROACH TO PROSTATI SPCOTIC ANIIGEN (PsA) ANO PROSTATE CANCTR SCREENING AN APPNOACH TO PROSTATE SPECIFIC ANTIGEN (PSA) AND PROSTATE CANCER SCiEENING I AN APPROACH TO COMMON UROLO6ICAL DISORDERS 41
 I A]ll APPROAGH TO EREGTILE DYSFUNCTION
Dr Chong Tsung Wen
HOW DO WE DEFINE ERECTILE DYSFUNCTION (ED)?
Any persons who subjectively complains of absent or poor quality of erectlon despite
sexual arousal is said to be suffering from erectile dysfunction. There is increasing evidence that
ED
can be an early manifestation of coronary artery and peripheral rrascltlar disease. Tl.rus ED should not
only be regarded as a QOL issue but also as a potential warninq sign
of cardiovascular dlsease.
WHAT IS THE INCIDENCE OF ED?
The incidence of ED ls high but the exact incidence may not be fully known as many sufferers do not
seek advice. Previously seen as an inevitable consequence of aging; recent advances in treatment
highlighted in the media has led to qreater public awareness and increasing demand fr-'i medical
treatment.
A lvell-conducted population study on agin9, the Massachuseits Male Aging study, showed the
prevalence of ED to be 50% among men above 50 years. This incidence increases 10% for every
decade of life thereafter. ln that study, most male suffer from mild to lnoderate ED wirh only about
1 O% has severe ED. Singapore is likely to have similar rates.
WHAT IS THE ETIOLOGY AND HOW DO WE CLASSIFY THEM?
Traditionally, the etiotogy of ED is classified as Organic or Psychogenic
Organic causes:
1 Artcriogenic;arterio-occlusivedisease,pelvicsurgery
2. Venous leakage
3. Neurogenic; peripheral neuropathy from diabetes, spinal trauma
HOW SHOULD I EVALUATE THE PATIENT IN THE CLINIC?
A full medical history including medications, previous admissions and surgery should be taken. The
severity of comorbidities may require moderation of sexual activity. While medications may be the
underlying cause of ED, they commonly also aggravate the condition. Lifestyle factors and possible
substance abuse such as alcoholism and smoking should also be noted.
A sexual history should include the onset and duration of the problem, presence of nocturnal or early
morning tumescence and a sexual assessment questionnaire such as the llEF score. Such questionnaire
forms the basis for diaqnosis and determines the severity. Conditions such as premature ejaculation,
infertility and sexual disorders should not be confused with ED.
Examination of the genitalia should include observation of the testicles, penile size and any
abnormalities such as penile nodules or curvatures. Older men with urinary symptoms may require a
digital rectal examination of the prostate for malignant changes. Blood pressure and peripheral pulses
examination are mandatory to assess for undiaglnosed or poorly controlled hypertension.
WHAT INVESTIGATIONS SHOULD I DO?
The only screening test required is a urine dipstick for haematuria, glycosuria or proteinuria which, if
present, will require fr.rrther work-up. Other investigations shoutd be directed by the history artd physical
examination. Glvcosuria should be followed up with fasting glucose and HbA'lc levels to diagnose
diaberes. Lipid proflles shoutd be included in the fasting specimen. Presence of significant lower urinary
tract symptoms or an abnormal rectal exam of the prostate should be followed by a discussion with the
patienr on PSA (prostate specific antigen) testing. Loss of libido, lethargy and findings of atrophic testis
may call for deterrnination of hormonal levels (morning testosterone (total and free) levels).
The Third Princeton Consensus orr sexual function and cardiovascular health has identified low risk
paiients as those without any significant cardiac history, symptoms or risk factors (< 3 risk factors).
These patients do not require further cardiac evaluation. lntermediate risk groups with significant risk
factors (= or > than 3) or uncertain cardiac conditions should undergo stress testing to clarify therr
cardiac status. High risk patients with su{ficiently severe or unstable cardiat: conditlons should be
referred lo the Cardioloqist.

4. tndocrine;testicularatrophy,orchidectomy, hypopituitarism
WHAT ARE THE KEYS TO SUCCESSFUL TREATMENT OF ED?
5. Penile abnormality; hypospadius, chordee, Peyronie's disease
6. Drugs;
A stepwise approach based on severity has been proposed but it has been more popular in clinical
practice to begin with the least invasive treatment therapy which is oral medication together with
. hypotensiveaqents:beta-blockers,thiazides
lifestyle chanqes and risk factor modification.
. anticholinergics:tricyclicantidepressants
. hyperprolactinaemiamedications:domperidone ,!. ORAL MEDICATION

" anti-androgens:cyproteroneacetate,cimetidine,oestrogens To date there are three available on-demand oral PDE5 inhibitors for treatment of ED; Sildenafil (Viagra),
. others: clofibrate. MAOIs Tadalafil (Cialis) and Vardenafil (Levitra). There is no data directly aoF,]paring the efficacy of the 3
. drugs of abuse: smoking, alcohol, heroin and methadone drugs. Ultimately the choice of drug depends on frequency of sexual intercourse and patient's personal
experience with each. Sildenafil and Vardenafil have efficacy of up to 12 hours, wrth Tadalafil beinq the
longer acting drug up to 36 hours. once-a-day oral dosing of Tadalafil (5mg) is now available. This form
Psychogenic cause: of therapy is particularly suitable for couples who prefer more spontaneous or more frequent sexual
1. Depression intercourse, with the advantage that dosing and sexually activity need no longer be temporally linked.
2. Stress Adverse reactions are usually a class effect related to PDE5 inhibition with some minor differences
(check with individual drug information sheet). The two main reasons for failure to respond to PDE5
3. Performance anxiety
inhibitors are either incorrect dosing or inappropriate drug (related to duration of action). ln addltion,
4. Traumaticexperiences
PDE5 inhibitors rely on release of rritric oxide from parasympathetic nerve endings following sexual
stimulation, without which the drugs will not work. Clinical trials have not demonstrated any effect on
Such distinction is neither cleat-cut nor always exclusive in clinical practice as ED of any organic cause
cardiac function or increase in myocardial infarction rates in patients receiving PDE5 inhibitors. However,
may over time develop a psychogenic component, such as, performance anxiety and depression.
concomitant use of Nitrates is an absolute contratndication.
Conversely, psychogenic causes may have an organic basis in terms of neurotransmitter imbalance

I AN APPROACH TO DYSTUNCTION AN APPROACH TO COMMON UROLOGICAL DIsORDIRS 43

42 AN APPROACH TO COMMON UROTOGICAL DISORDTRS AN APPROACH TO IRECIILE DY5FUNCTION ERECTILE I
 WARN the patients against abusing Viagra. Casual, non-prescriptive usage should be discouraged.
Should there be any suspicron of hypogonadism contributing to ED, a referral to a Urologtst or
overdosing, mixing with recreational drugs or excessive alcohol may lead to a grave outcome.
Endocrinologist is appropriate for further work-up before commencing testosterone replacenrent
therapy. Failure to respond to any of the oral PDES inhibitors will lead to consideration for alternative
therapies such as transurethral Alprostadil, intracavernosal injections or vacuum devices. DOS AND DON'TS OF INTRACORPOREAL INJECTIOI{
lntracorporeal vasoactive drugs include PGE'l (eg Caverjet), Papaverine, Phentolamine or combination
2. TRANSURETHRAL MEDICATION of these drugs. Bi-mixes (papaverine & phentolamine) or tri-mixes are more effective due to syrrergistic
action; with better side effects profile due to lower dose of each component is used. However,
MUSE (Medicated Urethral System for Erection) consist oI a pellet of prostaglandin-E1 (Alprostadil)
availability is limited.
ihat through the external meatus 2 - 3 cm into the urethra where it is absorbed into
is inserted
corpora cavernosa. Reported efficacy rate is 65%. Side effects include a burning sensation after
DO store Caveriet between 2-8 oC. Once reconstrtuted in the original container, it can be kept for 43
application.
hrs at roorn temperature or 7 days when refrigerated. DO NOT use if solution cloudy or particles seen
after mixing. DO NOT re-use the needle. Effects of PGEl are dose-dependent. Start with 'lO ug & titrate
3. INTRACAVERNOSAL INJECTIONS accordingly.
The most common agent used is Prostaglandin E1. lt gives a spontaneous and rigid erection with an
efficacy rate of B0%. Side effects include fibrosis at injection sites. Other combination agents include Do Nor inject > 40 ug. ln psychogenic ED. you might want to try the patient with 5 ug first. The drug
papaverine, pherrtolaming and alprostadil with efficacy rate of over 90olo. it does not potenttate the effects of Nitrates but DO NOT forget the effects of sex on the heart.
is safe;
Metabolism of PGEl in the penis and lungs is very rapid; inactive metabolites are excreted in the u1ne.
4. VACUUM ERECTION DEVICES
These devices create a vacuum around the penis that draws in blood resulting in'engorgement. DO inject directly into the corporeal cavernosum either at 2 o'clock or 10 o'clock along the penile shaft
Erection is maintained by a constriction ring placed at the base of the penis. Being a mechanical under asepttc technique. AVOID injecting into the dorsal veins, subcutaneous tissue or urethra. Press on
device, drug interaction and side effects are less common. The constriction ring should not be left for the injection site for 3 ntins to prevent haematoma.
prolonged period as it can cause ischaemia.
. WARN patient of the adverse effects (mainly local) eg priapism, pain, haematoma & penile fibrosis.
DO NOT use corporeal injections if pat;ents are predisposed to priapism eg sickle cell anemia, multiple
5. PEN!LE PROSTHESIS
myeloma or leukemia. DO NOT inject into the same site to avoid fibrosis.
' Penile prosthesis may be in the form of malleable or inflatable implants Patient satisfaction rate
is high and long term survival of the inrplant is 80% at 10 years. Cost and infection are 2 maior PRIAPISM is uncommon in PGEI unlike papaverine. lf the penis is still erected after scxual rntercourse,
considerations. advise the patient to do vigorous exercises egjumpinq. climbing the stairs or skipping. DO NOT hesitate
to refer to a urologist if above measures fail (especially if erection persist for more than 4 hrs).
6. VASCULAR SURGERY
Arterial or venous surqery has a limited role in very selected patients. While most men with ED can DOS AND DON'TS OF MUSE THERAPY
and choose to be managed by the family physician, some may bene{it {rom a Urologist referral and MUSE is an acceptable alternative as a first-line ED treatment. lnitial titration dose is 250 ug; DO NOT
rnclude a) Patients with penile deformity b) Patients contemplating combination therapy c) Patients prescribe beyond 1 000 ug. Absorption rate is somewhat unpredictable
requesting penile prosthesis d) Young patients with trauma.
REASSURE patient regarding safety of introducing into urethra. Patient's hesitancy & reluctance coujd
DOs AND DON'TS OF VIAGRA PRESCRIPTION be overcome by rncluding the insertion as part of the {ore-play.
VIAGRA is a safe drug proven to be effectrve for patients with ED. The effects are dose-dependent.
The adverse effects include headache, facial flushing, Gl upset, Iight sensitivity & rarely, bluish vision. DO NOT mix Viagra with PGEi or u/ith N,4USE. The effects, results and safety profile have not been fully
addressed. However, Do consider MU5E in penile prosthesis patient complaining of poor penile girth
'100
DO start with 50 mg and trtrate (max: mg). DO NOT start with > 25 mg in the elderly or those and insufficient glans rigidity.
with severe renal or liver impairment. Viagra is metabolised by hepatic cytochrome P450 enzymes.
REDUCE the dosage if the patient is on an1' drugs that inhibit this enzyme. DONOTuseMUSEwhenthesexual partnerispregnantwithoutacondom.Theeffectof PGEl inthe
ejaculate on the gravid uterus is not clearly known.
DO take Viagra 30 mins before sex on an empty stomach. A fatty meal would delay drug absorption.
DO encourage foreplay, adequate sexual stimulation (all 5 senses & erotic thoughts) for best results. DOs AND DON'TS OF VACUUM DEVICE
Without stimulation, Viagra would not work effectively.
Vacuum device (VD) rely on mechanical effects to produce an erection. If used properly, it may be the
least expensive and salesi method.
DO NOT prescribe Viagra to patients on long-acting NITRATES. By potentiating the action of nitrous
oxrde, it could lead to a cardio-vascular collapse. For patients on short-acting Nitrates e.g- sublingual
DO consider VD as an alternative {or all patients regardless of etiology except in severe Peyronies
GTN, extreme caution must be taken. Viagra must not be prescribed within 24 hr of taking the GTN.
disease. lt could be used in those who have failed other therapeuti( options including penile prosthesis.
DO NOT prescribe in patient with degenerative familial retinal diseases eg retinitrs pigmentosa.
Do choose a devrce based on appropriate size and patient preference for pump type - either battery
operated pump or manual. An oversized device may lead to suction of the scrotal skin into the cylinder.
AVOID Viagra in patrents with recent AMl, stroke, severe arrhythmia or hypotension. CAUTION
-using
in patient with poor cardiac {unction, severe cardiovascular disease or uncontrolled hypertension. DO
monitor the symptoms & BP in patients with hypotension even though Viagra's interaction with all 5 main
classes of anti-hypertensive was reported to have similar incidence of side-effecis compared to a placebo.

I
ANAPPROACHTOERECTILEDYSFUNCNON
44 AN APPRoACH TO CoMMON UBOIOT]ICAT DISORDERS I AN APPROACH TO ERECTILE DYSFUNCTION IANAPPROACHTOCOMMONUROLOGICALDISORDERS 45
 excessive pubic 10
DO use a water-soluble lubricant to obtain an air-tight seal and if necessary, shave any AN APPROAGH TO PREMAIURE EIAGULATION
hair. lntermittent pumping may produce a more engorged penis with
more satisfactory rigidity.
Dr Lee Lui Shiong
DO consider using tension band with a ventral notch if patient complains
of inability to ejaculate' Do NoT Consultant, Depafiment of Urology, Singapore General Hospital
penis'
apply the tension band beyorrd 30 mins to avoid ischemic in1ury to the
HOW DO WE DEFINE PREMATURE EJACULATION (PE)?
Do NoT use in patient with bleeding tendency or on anticoagulation therapy' The current definition of primary premature ejaculation (PE) is based on that proposed by the
lnternational Society for Sexual Medicine in 2008(1) - "... a male sexual dysfunctron characterised by
lnsummarysafe&effectivetreatmentoptionsforEDareavailableprovidedpropermeasuresare ejaculalion which always or nearly occurs prior to or within about one minute of vaginal penetration;
cardiovascular risk Risk
taken to a;hieve the optimal results. ED rtay be associated with an increased and inability to delay ejaculation on all or nearly all vagrnal penetrations; and negative personal
of patients with ED for further cardiac evaluation is important ln addition, although PDE5
stratification consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy."
physical stress ensuing vigorous
inhibitors themselves do not affect cardiac function, the unaccustomed
patients to a specialist early for
sexual activity may lead to cardiac related issues. lf necessary, refer these Therefore, men diagnosed with PE as a sexual disorder have short intravaginal elaculation latency time
a thorough assessment & advice prior to starting these
patients on ED treatment'
(lELT. less than one minute) with poor eyaculatory control. This has been shown to have negative impact on
both the patient and tlreir partners (2). Single men with PE are also affected.

Where previous de{initions of PE have not taken into account the impact of IELT, patients have
historically been erroneously diagnosed with PE
AN APPR0AGII T0 EREGTILE DVSFUNSTI0N: A FAMILY
WHAT IS THE PREVALENCE OF PREMATURE EJACULATION?
PHYSIGIAN'S PERSPE TNE
The prevalence of premature e.iaculation (PE) has been quoted as between 2o-30% (3,4). However, one should
distinguish 'PE' as a symptom or complaint from the patient, versus a diagnosis ol PE as a sexual disorder.
Dr Peter Moey Kirm Seng
Cmii oirecior SingHbalth Potyclinics, Pasir Ris Polyclinic
The presence of early ejaculation does not always represent premature ejaculation as a
patients presenting to Family Physician (FP) for Erectile Dysfunction (ED) frequently attribute it to sexual disorder.
anti-hypertensives such as
medications prur.iib"d for clrronic diseases such as hypertension. Some
establishing the temporal
beta-blockeri, do indeed predispose an individual to ED. ln this situation, It is now recognised that ejaculatory disorders in men repi'esent a spectrum, including lifelong PE,

sequence of events leading up to development of ED is imporlant. acquired PE, natural variable PE,and PE-like ejaculatory dysfunction(5).

patierlts occastonally stop chronic disease medications because of developmcnt of ED Clrronic HOW SHOULD I EVALUATE THE PATIENT lN THE CLlr\ilC?
disease control should take precedence over ED treatment, as
poor control o{ chronic conditions can
alcohol and poor control The patients clinical and medical history is crucial to diagnosis of PE. There should be specific fotus on
worsen ED besldes leading to other cardiovascular complications. smokitrg,
should be emphasised' the duration or symptoms, such as whether it is srtuational (specific partner or specific situation), length
of chrcnic conditions all contribute toward ED and appropriate intervention
of time from vaginal penetration to e.iaculation. degree of sexual stimulus and the impact of PE qn
patients and counselling offered quality of lite (QoL). lt is crucial to estabilsh the perceived amount of e.jaculatory control during cortus,
stress and depressiorr can cause ED and should also be explored in
professionals such as and the amount of distress and negative impact on the relationship resulting from a lack thereof. The
if indicated. lt may be helpful to involve family members and other healthcare presence of drug usage and concurrent erectile dysfunction (ED) should be established.
psychologists or psychiatrists
medical social *oik.rt, Family Service Centre personnel,

Physical eiiminatron should he aimed at identifying physical or structural abnormalities in the external
physical iitness for sexual activity should be assessed for patients who have been sexually/physically
taking, physical examinatlon and genitalia, such as Peyronie s disease, sexually transmitted diseases, phrmosis and other scrotal lesions.
inactlve prior to prescribing ED medications. After relevani history
Choice of medication and An examination of the neurological, vascular and endocrine may rqyeal other systemic disorders that
investigation, a irial of the appropriate PDE5 inhibitors may be prescribed. predisposes to male sexual dysfunction such as thyroid disorders and diabetes mellitus. There are no
patienieducation on pDE5 usage are important factors in the management of ED. Where an organic
pors are contra-indicated or ineffective, patients may then be referred routine laboratory investigations jndicated in the evaluation of PE, but are directed from abnormal
cause for ED is suspected or if
findings at clinical evaluation. A significant overlap in IELT has been observed between normal men
to the Urologist.
and those with PE, thouqh a median time of 5.4 minutes has been reported for normal populations
(6). Therefore, the use of IELT alone is not sufficient to diagnose PE. ln randomised controlled trials.
The FP may face ethical dilemmas when patients seek treatment
for sexual activities outside marriaqe'
discharge lris duties professionally, the female partner measures IELT with a stopwatch. The time period measured commences at vaginal
It would be appropriate for the FP to respect patients' choices and penetration and ends at the point of ejaculation. ln a situation where ejaculation occurs prior to
including ,uintuining patient confidentiality and dispensing advice on safe sexual practices.
penetration (ejaculatio ante portas), the IELT is defined as zero. ln practice, a stopwatch is not necessary
and where needed, patient estimates are usually sufficient.

WHY DOES PE DEVELOP?

The paihuplrysiology o[ lifel,ing PE has been widely studies in animal and human models of disease.
ln the physiological state, serotonergic stimulation in the medial preoptic area and the paraventricular
nucleus leads to prolongation of ejaculatory latency. Therefore, the pathogenesis of lifelong PE is based
on imbalances in serotonin neurotransmission and/or serotonin receptor functioning in the central
nervous system (7).

AN APPROACH TO COMMON PREMATURE EJACUTATION I AN APPROACH TO CCMMON UROTOGICAL DISORDERS 47

ou AN APPROACH TO COMMON UROLOGICAL DISORDIRS I AN APPROACH TO ERECTILE DYSFUNCTION
,i'

l
 Both genetic and epigenetic (8) factors may play a role in development of lifelong
PE. This is.based on THE ROLE OF THE FAMILY PHYSICIAN (FP)
oicuning in twins or in familial studies (9). There{ore lifelong PE is more likely an Patients with PE may find i1 dif{icult to come forth wilh their complaints. The detection of such
studiJs showinq PE
inherent disease. sexual disorders may need direct prompting by the physician especially if patients are hesitant. lt is
usually beneficial to have the patients sexual partner present during the consult, although it may be
on the other hand, acquired diseases, and situational or envircnnletlt:l factors 'l'lay cause acquired occasronally necessary to have complete privacy for the individual.
PE and other PE-like disorders.
Once identified, these patients will benefit from an initial assessment by the urologist. They may then
WHAT ARE THE KEYS TO SUCCESSFUL TREATMENT OF PE? subsequently be discharged to their FP {or continued care.

Appropriate treatment o{ PE requires identification of the subtypes of PE (5ee Algorithm)'

REFERENCES

TREATING LIFELONG PE 1. McMahon, C.G.. et al., An evidence-based de{inition of lifelong premature eiaculation: report
of the lnternational Society for Sexual Medicine (ISSM) ad hoc committee for the definition of
lnprimaryPE,psychologicalcounsellingmayhavealimitedrole'Themainstayoftherapyrelieson
patients although drugs ate premature ejaculation. I Sex Med, 2008. 5(7): p. 1 590-606.
medical tierapy.'No wiJely accepted cure is currently available for these
useful to portpon" the ejaculatory response. The goal of therapy is to
prolong the ejaculatory time 2. Patrick, D.1., et al., ORIGINAL RESEARCH-EIACULATORY DISORDERS: Premature Ejaculation: An
Observaiional Study of Men and Their Partners.
and rncrease eiaculalory control
The journal of sexual medicine, 2005. 2(3): p. 358-367.

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (55RIS) 3. Laumann, E.O., et al., Sexual problems among women and men aged 40-80 y: prevalence and
setraline correlates identified in the Global Study of Sexual Attitudes and Behaviors. lnt J lmpot Res. 2005.
These drugs are first Iine treatment in PE, and include dapoxetine,paroxetine'
1 7 (1): p. 39-57 .
and fluoxettne.
4, Hartmut. P, et al., The Premature Ejaculation Prevalence and Attitudes (PEPA) Survey: Prevalence,
previously, these agents have been prescribed on a daily basis. and shown to prolong the IELT in Comorbidities, and Professional Help-Seeking. European urology,2006.51(3): p.816-824.
various studies. A meta-analysis suggests that paroxetine exerts the strongest
e{fect (10). 5. Waldingel M.D., Premature ejaculation. Drugs, 2007. 67(4): p. 547-568.
6. Giuliano. F., et al., Premature ejaculation: results from a five-country European observational study.
as an on-demand oral
More recently, dapoxetine (30mg and 60mg) has been shown to be effective Eur Urol, 2008. 53(5): p. 1048-57.
pE. trials demonstrate prolon-oation of IELT from 0.9 minutes at
treatment fo; Randomised clinical
(11) Similardosedependent
7. tv1D, W, Tlrc neurobiological approach to premature ejaculation. I Urol, 2002. 168: p.2359-2367.
baselineto1.8min(placebo),2.8rrrin(30mg)and3'3min(60mg) B. Waldinger, 1,4., et al., Familial o.currence of primary premature ejaculation. Psyclriatric Genetics,
placebo, 30mg
improvements in lELi was also observed in another clinical trial comparing between 1998.8(l): p.37.
and 60mg (12). The clinical e{{ectiveness was apparent on first dose'
9. iern, P, et al., Prerrature and Delayed Ejaculation: Genetic and Environmental Effects in a
one to three hours Population-Based Sample of Finnish Twins. The;ournal of sexual medicine, 2007. 4(6): p. 1139-
Dapoxetine was approvecl for usage in singapore from March 201',l, and is taken
1749.
prior to coitus.
'10. Waldinger, M., Towards evidence-based drug treatment research on premature ejaculation: a
(7.7-13.AVo), diarrhoea critical evaluation of methodology. lnternational journal of impotence research, 2003. 1 5(5): p.
Common side effects of dapoxetine include nausea (16.5-30.6%), dizziness
(3.9-1 1.3%) and headache (64-13.6Y"). These adverse effects lead to drug discontinuation
in '1 37o, 309-3 1 3.
3.9 and 8.2% of patients (placebo, 30mg , 50mg) in the trial
(12)' 1 1. Pryor, J.1., et al., Efficacy and tolerability of dapoxetine in treatment of premature ejaculation: an
integrated analysis of two double-blind, randomised controlled trials. The Lancet. 368(9539): p.
yawning, nausea
There are short and long term side effects related to ssRls. The former include fatique, 929-937.
and perspiration. These are short term and disappear within the first month of starting treatment. 12. Buvat, J., et al., Dapoxetine for the Treatment of Premature E.iaculation: Results from a
Randomized. Double-Blind, Placebo-Controlled Phase 3 Trial in 22 Countries. European Urology,
The long term side effeds include weight gain and development of diabetes mellitus. A rare side 2009. 55(4): p. 957-968.
with ,13.
effect oi Ssttts include a.bleeding diathesis (1 3), which may be more pronounced in combination Weinrieb, R.M., et al., Selective serotonin re-uptake inhibitors and the rask of bleeding. Expert Opin
non-steroidal anti-inflammatory agents. Drug Saf, ZOO5.4(21: p.337-44.
All patients should be advised against stopping ssRl therapy acutely as it may lead to SSRI
14. Black, K., et al., Selective serotonin reuptake inhibitor discontinuation syndrome: proposed
disLontinuation syndrome ( l4).
diagnostic criteria. J Psychiatry Neurosci, 2000. 25(3): p. 255-61.
prior
ln patients with underlying psychological disorders, a formal psychiatric assessment is indicated
to starting SSRls.

SECONDARY PE
The successful management of secondary PE relies on identification and treatment of its underlying
cause. For example, secondary PE may occur as a complication of erectile dysfunction (ED). ln this
particular situation, the male partner hastens to complete the act of coitus before detumescence
occurs.The appropriate clinical management involves treatment of ED

AN APPROACH TO COMMON PREMAIURE EJACULATION IANAPPROACHTOCOMMONUFOIOGICALDIJORDERS 49

48 AN APPROACH TO COMMON UROLOGICAT DISORDIRS I AN APPROACH TO COMMON PNEMATURE EJACULATION
 SUGGESTED ALGORITHM FOR MANAGEMENT OF PREMATURE TREATMENT OF PE
E.!ACUI-ATION The most common behavioural treatments for PE are the stop-start method and the squeeze technique.
The support for behavroural retraining comes from the hypothesis that PE occurs because the man
fails to appreciate the sensations of heightened arousal and recognize the feelings of ejaculatory
ls it premature inevitability (2). The premonitory sensation is rhe feeilng that a man getsjust before he reaches'the
eja cu latio n ? point of no return', also called 'the point of inevitability'. Each man has a certain threshold of pleasure;
after he crosses it, he cannot stop his orgasm. One can learn to become more aware ofthe sensations
experienced prior to ejaculation. The following set of instructions can be given to a patient: 'You can
practice recognizing the premonitory sensation through masturbation and begin to develop some
PE Like dysfunction control. During masturbation, one can stop long enough for the excitement levels to drop slightly
ls it primary (probably a few seconds or a bit longer), but without allowing your erection to do down. When you feel
or secondary PE? ready, start stimulating yourself again until the arousal levels build up, and then stop again. Repeat this
stopping and starting again (three times rn all); then on the fourth time continue until you can let go and
enjoy your orgasm'(3). Depending on the man, this whole process may take weeks to months to learn.

The stop-start technique is more popular among sex therapists because tt is easier for health
Primary PE professionals to explain and for patients to use (4-5). Couples can learn to incorporate 'stop-start'
Itifetong) technique into their sexual script. The stop - start approach involves an exercise in 'communication' and
comprises these five steps:
1. The couple will stop having penetrative sex for a while. This ban serves to decrease the man's
performance anxiety.
2. During a couples first lessons, the woman uses her hand to arouse the man and stops the motron
MedicaI therapy Treat predisposing when he signals her to.
(SSRls) co ndition 3. This happens three or four times on any one occasion before he eventually ejaculates.
4 The next step is the stimulation of the penis with the aid of lubrication. This step is thought to
be essential as the initial 'dry' stimulation of the penis does not adequately match the sensations
experienced by the man once vagirial penetration is reintroduced.
5. The couple then integrates this technrque into intercourse experiences with frequent'pauses'.
AN APPROAGIN TO PREMAIURE EJAGUI,ATION:
A PSYGTIIATRIST'S PERSPEGNUE It is always useful to go on practicing stop-start from time to time cven afler the man has overcome his
PE (3). The reason behind this recommendation is that certain situations can increase the likelihood of

Dr Ng Beng Yeong a relapse of PE, for exanrple, a period of time without any sexual activity, which can happen when the
Senlor C6nsultant, Department of Psychiatry, Singapore General Hospital wile becomes pregnant.

WT.IAT IS PE? Sexologists Masters and Johnson developed a variation of the start-stop technique, called the squeeze

ln DSM-5. premature ejaculation (PE) is a persistent or recurrent pattern o{ ejaculation occurring lechnique (2-4). With this technique, rather than merely stopping stimulation to the penis, the man3
partner is instructed 10 grasp the corona of his penis with her index and middle finger against her thumb,
during partnered sexual activity within approximately 1 minute following vaginal penetration and
before ihe individual wishes it (1). lt must have been present for at least 6 months and must be applying firm pressure for approximately 20 seconds. l-his will cause the man to lose his urge to ejaculate.
CauLiorr rreeds to be exercrsed as it can be painful if too much pressure is applied. For this reason some
experienced orr almost all or all (approximately 75% -- 100%) occasions of sexuai activity. Estimated
sex therapists lrave modified the technique that the man performs this manoeuvre himself. Locally, some
and measured intravaginal ejaculatory latencies (IELT) are hiqhly correlated as long as the ejaculatory
latency is of short duration; therefore, self-reported estimates o{ ejaculatory latency are sufficient
women may not cooperate with this treatment as they are reluctaiit to touch the mans penis (4).
for diagnostic purposes. with the new definition of premature (i.e., ejaculation occurring within
:
approxinrately 1 minute of vaginal penetration), only 1% 3% o{ men would be diagnosed with
Sorne men may object to the stop-start technique and squeeze technique as manual stimulation is

ihe disorder (1
).
DSM-5 also highlights the need to consider multiple contributing factors when evaluating a patienr
with any sexual dys{unction. These factors include: 1) partner fac[ors (e.g., partners sexual problems,
partner,s health status); 2) relatronship factors (e.g., poor communication, dlscrepancies in desire
for sexual activity); 3) individual vulnerability factors (e.9., poor body image, hrstory o{ sexual or
emotlonal abuse), psychiatric comorbidity (e.9., depression, anxiety), and stressors (e-9., job loss,
bereavement);4) cultural/religious factors (e.g. inhibitions related to prohibitions against sexual
attitudes toward sexuality); and 5) medical {actors relevant to prognosis, course, or
treatment (1).
not culturally acceptable to them. Fear and guilt that masturbation may have been 'weakening'seems
stronger in Asian cultures. Also. not all patients are able to identify the 'point of inevitability'; they may
have a short arousal phase and an almost non-existent plateau phase of their arousal cycle. Behavioural
treatment might be much more successful in men with premature-like elaculatory dysfunction than in
men with lifelong or acquired premature ejaculation (2). ln premature-like ejaculatory dysfunction, men
complain of premature ejaculation, but the IELT is in the normal range or even has a long duration.
Sensate focus can also be useful. The couple is encouraged to spend time in mutual pleasuring involving
nongenital massaqe and caressing (2). This reduces the genital focus of the ejaculatory control process,
and again conditions the man to higher levels of sensation and stimulation. Sensate focus requires a
cooperative partner and sufficient time to follow the programnre properly. lf the usual 'order' of sexual

50 AN APPROACH TO COMMON UROLOGICAL DIsORDERS I AN APPROACH TO COMMON PREMATURE EJACUUTION AN APPROACH TO COMMON PREMATURE EIACUTATION I AN APPROACH TO COMMON UROLOGICAL DISORDERS 51
 events is such that the man ejaculates before his partner is stimulated, this process can be altered so
that attention is glven to the woman's satisfaction and possibly. orqasm, be{ore or after vaginal entry
11 AN APPROACH TO HAEMATOSPERMIA
occurs (3). The treatment of PE may change aspects of foreplay rather than ejaculatory control. Also,
Dr Henry Ho
some couples may forget the coniinuation of pleasuring which is possible after ejaculation.
Consultant, Deparlment of Urology, Singapore General Hospltal
A man may seek treatment for PE even if he has no partner. For such cases, it is important to provide
him with the relevant information and let him learn specific techniques such as stop-start while WHAT IS HAEMATOSPERMIA?
masturbating. lt is important to assist the man psychologically to develop his own sexual confidence, Haematospermia is defined as the presence of blood (with or without clots) in the ejaculate. There are
increase his repertoire of sexual skills and thus enabling him to look for a partner (4). many causes of haematospermia including infections, malignancy, and inflammatory causes as detailed
in Table 1.
COMPLICATIONS OF PE
Erectile dysfunction can be a distressing complication of premature ejaculation. Lack of confidence in
Table l. C.ruses 6[ Haemalospermia
one's own ability to avoid PE can lessen his desire for sexual contact and undermine his erection Tlris
can lead in some instances to the avoidance of sexual situations altogether. More intensive work will Aetiotogy Ctinicat Featu!'e
be required in the treatment of such complicated cases. Psychotherapy might be helpful for the man
BehavioraI lsotated episode triggered
who is prepared to examihe all aspects of a {ailed relationship, sexual and otherwise (5).
Excessive sex or masturbation by particu[ar behaviour
lnterrupted sex
REFERENCES
Pro[onged sex abstinence
1. Draqnostic and Statistical Manual of Mental Disorders, Fifth Edition. DSM-5lAmerican
Psychiatric Association. 201 3. lnfection lrritative genitourinary symptoms
2. Richard Balon et al. Delayed and premature eyaculation. ln: Clinical Manual of Sexual Disorders. Gram-negative uropathogens AbnormaI urinatysis / cutture
Edited American Psychialric Publishing, 2009, pp. 273-304. Sexuat[y transmitted disease
3. Vicki Ford. Overcoming sexual problems. London: Robinson. 2005. \ Mycobacterium tubercutosis
Schistosomiasis
4. Ng Beng Yeong. Cominq of age: an integrated approach to premature e.jaculation. Singapore
Ec hi noccrccus
Family Physicians 2005, Vol 31. No 2 (Srrppl), AprilJuneZAO5:42-45
5. I'Jg Beng Yeong. Treatmentof difficult cases and advanced counselling techniques. ln: lnftammatory lrritative genitourinary symptoms
Premature ejaculation how to investigate and treat. Edited by Peter Lim Huat Chye. Society for
- Prostati tis AbnormaI physicaI findings
Mens Health Srngapore. 20'1 1, pp.45-50. Epididymo-orchitis AbnormaI urinaLysis / culture

Neoplastic AbnormaI physicat findings

Btadder or imaging
Prostate
Urethra
Testis

Structural Voiding symptoms

Ectopic prostatic tissue
Prostatic poLyp / stone / cyst
UrethraI stricture / fistuLa / diverticuLum

Systemic Systemic disease comptaints

Amytoidosis
Bteeding disorder
Chronic liver disease
UncontroLted hypertension

Trauma History of trauma /

Prostate biopsy / treatmenl instru mentation
Penile injections
Hemorrhoid injections
UrethraI instrumentation

Vascutar Associated with hematuria

Arteriovenous matf ormations
Btadder neck and prostatic varices.
Hemangiomas, tetangiectasia

52 AN APPROACH TO COMMON UROLOGICAL DISORDIRS I AN APPROACH TO COMMON PREMATURE EJACULAIION ANAPPROACHTOHAEMATOSPERMIA IANAPPROACHTOCOMMONUROTOGICALDISORDERS 53
 ALGORITI-IM FOR AN APPROACH TO HAEMATOSPERMIA
HOW DO I EVALUATE THE PATIEI{T?
history, demographic, risk factors
The evaluation of haematospermia should be directed by the clinical
and urinalysis.
History
AcompleteclinicalhistoryisrequiredtoexclUdepseudo.haematospermiawhichincludesnon- Exctude Pseudohaem atospermia
partner source The duration
reproductive tract source e.g haematuria, external genitalia iniury or LUTS
symptoms and genital
and frequency of haematospermia along with associated lower urinary GeniiaI symptoms Associated LUTS
symptoms like pain ciuring ejaculation or sexual intercourse are important' Sexua[ /systemic disease

partners, presence of barrier protection,

sexual history of the patient including number of sexual
prolonged abstinence can polnt to
frequency, pioionged or intense intercourse or masturbation and
or pseudo-haematospermia. The presence or absence of constitutional
the cause of haematospermia
,yrp,o., like night sweat, bony tenderness, loss of appetite/loss of weight or history of bleeding
disorders, liver disease or anti platelets medlcatlon are also important' Urologist reterral
Phvsicat examina!:!qn Abnormat frndinos |---...)t
may rarely be the presenting Genitatia and prostat ,i
Travel history to countries endemic of schistosomasis and tubercutous -1 -A
symptom of genitourinary infection via these organisms'

as causes of haematospermia
Recent instrumentation like prostate biopsies is Llsually clinically apparent

KEYS TO SUCCESSFUL MANAGEMENT OF HAEMATOSPERMIA

in examining the
while the physical examinatron may be routinely normal, care must be taken lnvestiqaiions AbnormaI urine test
of trauma, sexually transmitted disease, epididymis orchitis or external
extern.:l genitalia for signs Urine tests and and cutture
be
,orr.", oJ bleeding as the ca'se of haematospermia. Abclominal examination should also cu Itu re
prostatitis, abnormality,
per{ormed while a per-rectal examinatiorr of the prostate for evidence of Serum PSA
mass, prostate size and rectal abnormality is critical' STD screen
Semen cutture Etevated PSA
INVESTIGATION
The presence ol haematospermia can be confirmed with inspection
of a sample of ejaculate obtained
A urinalysis will yield the presence of corrcurrent urinary tract abnormalities, and a
in a condom.
(PSA) would indicate the presence of prostatitis or prostate cancer'
serum prostate specift antigen
presence of high risk sexual behaviour, sexually transmitted disease
screeninq for
where thls is
gonorrhea, chlamydial ancl HIV test should also be initiated'

SemencultureandexpressedprostatiCsecretionsmayidentifythecaUsativeorganisminbacteriaI Em pirica L Recurrence /

application has not been useful'
prostatitis presenting with haematospermia. Otherwiie, its routine clinical anti biotics Persistence

HOW DO IMANAGE HAEMATOSPERMIA?

of the patient
lv.lost causes of haematospermia are benign in nature, and treatment relies in assurance
andinaIlyingtheirfearSafteradequateclinicalevaluationandinvestigation'Empiricaltreatn]entWith
is suspicious of prostatitis The role of
flLroroqurnol"ones for 2 weeks may be prescribed where there
prostate
definitive treatment will apply to patients where a definite organic cause is found such as
caicinoma.

WilEN 15 A REFERRAL TO A UROLOGIST NEEDED?

persistence of haematospermia for
A re{erral to an urologist should be considered in patients with
more than 3 months, elevated PSA or abnormal urinalysis'
nnyputi.ntr*itr,suspicionofstructuraiabnormalityorabnormalprostateexaminationshouldalso
be relerred for Iurther evaluation.

AN APPROACH TO HACMtrOSPERMIA I AN APPROACI{ TO COMMON UROLOGICAT DISORDERS 55

54 AN APPROACI{
-IO
COMN4OI.I UROLOGICAL DISORDERS I AN APPROACH TO HAEMATOSPEFMIA
 Any predilection for bleeding should be sought, such as asking about petechiae, ecchymoses and other
AN APPROAG}I TO HAEMATOSPEBMIA IN haematomas that may be present. Antiplatelet drugs and anticoagulant use should be enquired about.
PRIMARY PRACTIGE
PHYSICAL EXAMINATiON
Dr Kwong Seh Meng The patient's blood pressure should be noted as severe hypertension is associated with haematospernria.
Deputy Head, Medicat Operations, Fullerton Healthcare Group Fever and tachycardia may indicate svstemic causes.

Haematospermia is the presence of blood in the ejaculate. The incidence is estimated at 1 in 5,000
The abdominal exam should assess for signs of blunt trauma and lymphadenopathy.
new patients referred to urology clinics (1). The true incidence in the community is probably hlgher
patient. lt may also be The penis should be inspected to rule out obvious lacerations, trauma or lesions that may contribute [o
as most ejaculations are intravaginal, and bleeding not apparent to the
the bleeding. The scrotum, epididymis and testes should be examined for masses, and the vas deferens
underestimated as most cases are transient, and may not prompt medical attention. In men less than
palpated along their course to check for irregularity or nodularity, which may suggesr tuberculosis.
40 years of age, haematospermia is most likely benign.

The digital rectal exam should note the prostate size, tenderness, fluctuation, symnretry, firmness and
Some men will not look at their semen post ejaculation. and as such. haematospermia may
be
nodularity. An attempt should be made to palpate the semrnal vesicles (normally, the seminal vesicles are
noticed by their partners or picked up after seeing blood-stained linen
non-palpable). The presence of a midline cyst may indicate the presence of ejaculatory duct obstruction.

Forthe patient, this finffng of bleeding can be terrifying. The usual first point of contact is a {amiliar
General Practitioner and most cases can be effectively rranaged as such
TREATM ENIT FOR I-IAEMATOSPERMIA
Antibiotrc therapy is incjicated in cases where an infectious etiology is suspected. l-he duration of therapy
The causes of haematospermia broadly include: is usuall;r 2 weeks, and choice of therapy is usually a fluoroquinolone that penetrates the prostate well.
1. Prostate: Recent TRUS-guided prostate biopsy, prostatitis, prostatic cysts, prostate cancel Alternatively, a combination of trimethoprim/sulfamethoxazole and doxycyciine will adequately cover
prostatic telangectaisa/varices, recent treatment for prostate diseases ( TURB brachytherapy) enterobacteriae and chlamydial infections. The r-rse of NSAIDs can reduce concomitant inflammation.
Bleeding diatlresis or other systemic disorders should be managed accordingly if already previously
2. Urethra: Urethritis, cysts, polyps, condylomata and strictures
known.
3. Seminal Vesicles: Seminal vesicle cysts. amyloidosis
4. Infections: TB, HIV HSV, Chlamydia trachomatis, schistosomrasis When to re{er to an uroloqist
5. Trauma: haemorrhoidal injections, urethral self-instrun-rentation, testicular or perianal blunt trauma.
i. Persistent haematospermia ( > 2 montlrs) or recurrent haematospermia
6. Systemrc Disorders: Hype(ension, chronic liver disease, amyloidosis, lymphoma, bleeding diatheses.
ii. All patients with concomitrnl haematuria on UFEME

A practical approach for the GP would be thus iii. ln men 40 years or oldet especrally with associated symptoms of fever, chills, weight loss or bone
1. History, pain or elevated PSA.

2. PhysicalExamination
3. Investigations, especially for red flag conditions that require relerral IDEAS, CONCERNS AND EXPECTATIONS
4. Addressing the ldeas, Expectations and Concerns of the patient. It should be noted that addressing the patients ideas, concerns and expectations should be applied
throughout the consultation process and not just at one instance.
HISTORY ln sexually active patients at risk of STl, it is an opportune moment to assess sexual practices and
advocate safe sex/ risk reduction strategies.
3 key factors help guide further management: Age of the patient, duration of the symptoms and
presence of associated symptoms or risk factors.
Well-intormed patients are also more Iikely to seek background information (internet) prior to clinical
i. ln men younger than 40 years, history should be {ocused on behaviour related haematospermia consultation. They may harbour their own beliefs about prolonged sexual abstinence, excessive
(sexually
such as exceisive masturbation, vigorous intercourse, and infectious etiologies ,nasturbation or rigorous sexual intercourse. An open mind and a non-judgemental consultation will work
transmitted infections, STls) best in such situations to address their underlying concerns.
ln men above 40 years of age, anaiomic abnormalities and abnormal growths should be
considered. Most patients would benefit from reassurance that haematospermia is usually selfJimiting
ii. persistent or recurring haematospermia, such as 10 episodes or more persisting for 1 2 weeks and would resolve spontaneously in around a few weeks or approxrmately 1 0 e.iaculates. They also need
require further evaluation. to be advised that haematospermia may also change in colour from red to rust brown gradually.
iii. The presence of lower urinary tract symptoms such dysuria may suggest urethritis. cystitis or
prostatitis. Pain with ejaculation may include prostatitis or an obstruction of the ejaculatory ducts. olcier patients may be worried about cancer, or conversely, choose to ignore their symptoms
Voiding symptoms may hint towards concomitant bladder or bladder oullet conditions or completely. The caveat is "to comfort always" and it is help{ul to encourage them to come forth
anatomic abnormalities. Although rare in this setting, the presence of significant bony pain may for early consultation.
suggest prostate cancer with bony metastases.
REFERENCES
The history should also elaborate on trauma, in{ections and bleeding disorders.Any recent ureLhral 1. Leary, F.J, Aguilo, JJ Clinical significance of hematospermia. Mayo Clin. Proc. 1974;49:815*817
instrumentation can give rise to haematospermia. The presence of dysuria and urethral discharge 2. )inza 5, Noguchi K, Hosaka M. Retrospective study of 107 patients with hematospermia. Hinyokika
will point towarcls UTly STDs. Concomitant macroscopic haematuria shc-uld usually prompt a referral Kiyo. 1997 Feb;43(2):103-7.
to the urologist.

56 AN APPRoACH To CoMMoN UROLOGICAL DIsORDERS i AN APPROACH TO HAEMATOSPERMIA AN APPROACH TO HAEMATOSPERMIA I AN APPROACH TO COMMON UROLOGICAL DISOROERS !
 12 AN APPROAGH TO NON.TRAUMATIG UROLOGIGAL
The patient s i:ladder should be decompressed by inserting a transurethral 1 4 to 1 8F Foley catheter.
Urethral catheterization must be done under a sterile technique. After gently passing the catheter,
EMERGENCIES the balloon should be inflated with 10 ml of water. After catheterization, lt is crucial to reduce the
penile foreskin to its normal anatomic position to prevent the development of paraphimosis. lt is also
A,/Prof Weber Lau Kam 0n helpful to document the amount of residual urine drained and the colour of urine after catheterisation.
Senior Consultant, Depaftment of lJrology, Singapore General Hospital Occasionally, suprapubic catheterisation may be required in patientswho have a history of urethral
stricture or trauma, and this should be performed only by those experienced in the procedure.
WHAT ARE COMMON EMERGENCIES?
lf the patient is stable and comfofiable, he may be seen electively at the earliest possible urology
The family physician plays a very vital role in the early diagnosis and initial management of uroloqic
appointment. Ilowever, immediate referral to the emergency department is necessary in patients
emergencies as delay may result in significant pain and sequelae to the patients' who remain distressed despite catheterisation, are haemodynamically unstable. develop macroscopic
haematuria or fever with purulent urine.
The {ollowing are urological conditions that will need urqent treatment and referral to the urologist:
1. Acute ureteric colic ACUTE SCROTUM
2. Acute urinary retention
Acute scrotum refers to an acute painful swelling of the scrotum or its contents, accompanied by local
3. Acute scrotum signs or general symptoms. lt should be treated as an emergent condition requirinq prompt assessment.
4. Priapism Although there are many dif{erentials. the three commonest diagnostic possibilities are testicular torsion,
5. Paraphimosis epididymal orchitis. and appendage torsion.
6. Fourniers gangrene
Among these, the early recoqnition of testicular torsion is by far the most critical. The diagnosis
ACUTE URETERIC COLIC of testicular torsion should be based on clinical suspicion. Every case of acute scrotum should be
considered testicular torsion until proven otherwise. The age of the patient has limited value in
Ureteric colic is a complaint that often brings a patient to see the farnily physrcian. The nature of
discriminating between testicular torsion from other aetiologies of acute scrotum.
the loin pain is usually quite classicai. However, findings from physical examination are usually
unremarkable. Presence of peritoneal signs may point to other differential diagnoses such as
Typically. physical examination reveals a tender and asymmetrically high-riding testis on the affected side,
abdominal aortic aneurysm, diverticulitis, appendicitis, and gynaecologic disease that may mimic
with the long axis of the testis oriented transversely, or the epididymis may fre located anteriorly.
renal colir:.

Time is of the essence in this urological emergency since pain lasting more than 6 h is highly associated
A fever and sick-looking patient in whom there is a suspicion of in{ection with concomitant upper
wrth testicular death if ischemia is not relieved. Therefore, emergent surgical exploration is the treatment
urinary tract obstruction is an eme(gency. Resuscitation with inlravenous fluids should be immediate
of choice when the clinical suspicron for testicular torsion is strong.
and intravenous antibiotics started. Emergent referral to urology is needed as the obstructed kidney
miqht need to be drained percutaneously bv a nephrostomy. lvlost routine laboratory investigations cannot exclude testicular torsion. Doppler ultrasound examination
may be helpful only if it is readily available and to exclude epididymo-orchitis which usually can be
preliminary investigations such as urinalysis to look for haematuria and pyuria as well as a KUB X-ray
treated medrcally.
can be performed by the family physician. lf the findings of urinalysis are normal, one should consider
other differential diagnosis.
PRIAPISM
otherwise, in a stable patient, initial treatment with analgesia should be started in clinic Both Priapism refers to prolonged erection that is unrelated to sexual arousal. Although the corpora
inlramuscular and rectal NSAIDs such as indomethacin and intramuscular opioids are effective to cavernosa are typically rigid and filled with stagnant blood, the glans and corpus spongiosum
reduce the pain (1 ). However, patients experience more adverse etfecrs, such as vomiting,
when
rernarn tlaccid.
using opioids (particularly pethidine) than when using NSAlDs. Nevertheless, NSAIDs such
as

ketoiolac should be used cautiously in the elderly, patients with pre-existing renal diseases, and Priapism can be subdivided into low-flow and high{low variants b*ised on the penile arterial inflow
those with dehydration. state. High-flow priapism usually results from perineal or straddle trauma. Erection is usually partial
with little pain. As there is still continuous inflow of oxygenated arterial blood, patients with high-
l,/lost patients who respond to the conservative treatment may be sent home with oral
analgesia and
flow priapism suf{er less complications, and it is usually being managed conservatively first. Selective
referred electively to the urologist. Medical expulsive therapy, using tamsulosin or terazosin, can
be
angroembolization of the damaged central artery may be considered in refractory cases.
'lOmm to reduce pain and expedite stone passage (2). Patients
considered for patients with stones <
with intractable pain, {ever, nausea and vomiting and gross haematuria will require urgent urological Low-flow (ischemic) priapism rs painful and requires emergency treatment as delay intervention will
attention. result in ischaemic damage of the corpora cavernosa and permanent erectile dysfunction. The causes of
ischaemic priapism can be classified broadly into drug- related, neurologic, neoplastic and hematologic
ACUTE URINARY RETENTION causes such as sickle cell disease etc.
ftrll
Acute urinary retention is defined as the sudden inability to pass urine, which is associated with a
preceded by a history of
bladder and lower abdominal pain. tt is seen predominantly in men and usually
obstructive lower urinary tract symptoms. lt is usually secondary to bladder outlet obstruction
for which
include
the most common cause is benign prostatic hyperplasia. Other causes of acute urinary retention
prostate cancer and urethral Strictures.

53 AN APPROACH TO COM]MON UROLOGICAL DISORDTRS I AN APPROACH TO NON'TRAUMATIC UROLOGICAL EMERGENCIES ANAPPROACHTONON.TRAUMATICUROLOGIGLEMERGTNCIES IANAPPROACHTOCOMMONUROLOGICALDISORDERS 59
 ln many cases of priapism, rf the presentation is early, conservative treatment such as physical exercise
(such as asking patients to climb stairs), or application of ice packs may eifect detumescence. lf these
measures fail, the next step is corporal blood aspiration. The aspirated blood should be sent for blood
gas measurements to determine whether it is low-flow (low pH, low Po2, high Pco2) or highJlow
(normal pH. high Po2, Iow Pco2) states. lf it rs still not successful, warm salrne irngation and injection
oi an alpha-adrenergic receptor agonist such as dilute phenylephrine (concentration of 0.1 to 0.5 mgl
'1
mL, and 1-mL injections made every 3 to 5 minutes for hour) should be attempted in patients with
ischaemic priapism. Urgent surgical shunt procedures remained as a last resort if all measures fail to
result in detumescence.
PARAPHIMOSIS
Paraphimosis occurs in situation when one fails to reduce the entrapped penile foreskin distally back to
its usual position overlying the glans penis. This happens not infrequently to uncircumcised men after
urinary catheterisation or clinical examination when the foreskin is not replaced to its normal position.
The tight distal foreskin forms a constricting band on the penile sha{t resulting in progressive glans
swelling due to impairedvenous and lymphatic drainage. This will further make reduction of foreskin
distally more diff icult.
Treatment of paraphimosis is urgent reduction of the foreskin. Analgesia can be achieved by the
applicatron of topical lignocaine gel, local penile nerve block or possibly conscious sedation. The glans
and penile tip are compressed with gloved hand to reduce the swelling so that the oedematous foreskin
can be pulled distally, back to its natural position. Should this measure fails, a dorsal slit through the
paraphimotrc band should be performed. The patient should then be referred to the urologist for
follow-up electively as circumcision may be indicated to prevent recurrence.
FOURNIER'S GANGRENE (FG)
It is a rare but rapidly progressive form of necrotizing fasciitis which affect the perineum and exterrral genital
area with possible involvement of the abdominal wall. The cause of FG is mainly polymicrobial aerobic and
anaerobic synerqistic infection with colorectal, genitourinary or skin as the primary infection site. lt should
be considered in patients who are immuno-suppressed such as patients who are diabetics. alcoholic or
on long term steroid.
AN APPROACH TO IUON.TRAUMATIG UROTOGIGAL
EMERGEI'IGI ES: A FAM I LY PHYSICIAN'S PERSPEGfl UE
DrTung Yew Gheong
Consultant and Head, Toa Payoh Polyclinic,
National Healthcare Group Polyclinics
Patients with non-traumatic urological emergencies frequently seek help from their Family physicians
as their first point of medical contact. While the collectlve incidence of non-traumatic urological
emergencies like acute ureteric colic, acute urinary retention, acute scrotum, priapism, paraphimosis and
Fournier's gangrene is not high, the trmeliness and appropriateness of the initial management by Family
Physicians, not only potentially relieves pain, but also has an important bearing on the eventual clinicai
outcomes for this group of patients.
ln the management o{ patients with urological emergencies, the Family Physician has the advantage
of having the background knowledge of their patients' medical history, including the presence of any
underiying chronic diseases, past surgical history and medication history. Coupled with the privileqe of a
well-established doctor patient relationship, the Family Physician is in the ideal position to help patients
with the initial rnanagement of their conditions.
ln addition. with the rapidly aging population and longer life expectancy of our population, the
incidence of acute urinary retention in our population is expected to rise (1). Family Physicrans have an
expanding role in helping to manage these patients within the community. For example, the simple
office procedure o{ urethral catheterization in suitable patients can help bring immediate relief to
patients and avoirl a hospital emergency department visit. With the initial management performed at
the prinrary care level, an early outpatient uroloqy referral can then be arranged subsequently, bypassing
the busy emergerrry services.
REFERENCES
1. Meigs JB et al, lncidence rates and risk factors for acute urinarv retention:
the health professionals follow up study. J. Urol. 1 999 Aug; 162(2):376-82

Clinically, tlre patient is usually febrile and toxic looking. The involved skin appears oedematous,
erl^hematous and indurated with crepitation. There may also be skin necrosis, or blistenng with purulent
collection. Despite a multidisciplinary approach that includes active resuscitative support, intravenous
broad-spectrum antibiotics, followed by early aggressive surgical debridement of all involved tissues, the
mortality rates are still very high.

REFERENCES
1. Holdgate A. etal. Nonsteroidal anti-in{lammatory drugs (NSAIDS) versus opioids for acute renal
colic. The Cochrane Library issue 1 2009.
2. Christian Seitz a. et al., Medical Therapy to Facilitate the Passage of Stones: What ls the
Evidence? European Urology 56 \2009) 455 - 47 1 .

AN APPROACH TO NON.TRAUMATIC UROLO6ICAL

60 AN APPROACH TO CON4MON UROLOGICAL DIsORDERS I AN APPROACH TO NON.TNAUMATIC UROLOGICAL EMERGENCIES EMERGENCIES I ANAPPROACHTO COMMON UROLOGICAL DISORDERS 6I
 13 ANAPPRoACHT0 LArE-0NSEIHYPoGoNADISM (LoH)
Dr NorAzhari Bin Mohd Zam
Consuttant, Depaftment of Urology, Singapore General Hospital
WHAT IS LATE-ONSET HYPOGONADISM?
singapore is facing a rapidly ageing population due to an increase in life expectancy and reduced
fertility rates. The Government's recent white paper on population estimates that there will be more
than 900 000 citizens aged 65 and above by the year 2030. Chronic illnesses and their associated
disability deserve increasing importance to improve quality of lite in the silver years.
Androgen levels, specifically testosterone, decline over a mans lifetime. The decline in men is more
ln the clinic, the FT level is best calculated by measuring the total testosterone level. SHBG and serum
albumin level. The calculator is available on the lnlernational Society for the Study of the Ageing Male
(ISSAM) website - www.issam.ch.
3. Follicle stimulating hormone (FSH), Luteinizing Hormone (LH)
and Prolactin (PRL)
lf testosterone level is found to be low, assessment of the hypothalamidpituitary axis with measurements
of serum FSH, LH and PRL are advised to exclude a pituitary pathology.
WHAT ARE THE KEYS TO SUCCESSFUL MANAGEMENT OF LOH?
Before embarking on testosterone replacement therapy (TRT), there should be an informed discussion
with the patient regarding the potential benefits and risks of therapy. With proper monitoring,
TRT is

graduJl, unlike the more precipitous decline in estrogens levels experienced by women during safe and can improve the quality of life of patients with LOH.
i,"noprrru. This can lead to a clinical condition known as late onset hypogondadism (LOH).
C ontra i nd ications:

Testosterone has wide ranqinq actions beyond its reproductive functions. lt preserves bone and 1. Patients with prostate or breast cancer
muscle mass, stimulates red blood cell formation and acts on mental functions such as rnood 2. Significant erythrocytosis with haematocrit levels of > 52%
and energy. 3. Known liver dysfunction

HOW DO I RECOGNISE AND EVALUATE LOH? Relative contraindications:

Clinical manilestations
'l
. Lower urinary tract symptoms suggestive of significant bladder outlet obstruction from benign
These include: prostatic hyperplasia
'1. Diminished sexual desire and erectile quality, particularly nocturnal erections 2. Obstructive sleep apnoea
2. Chanqes in mood and drive, leading to decreased intellectual capacity, fatigue, depressed mood
Metabolic syndrome and low testosterone:
and irritability
3. Decrease in lean body masswith associated reduction in muscle mass and strength
There is increasing evidence of a relationship between metabolic syndrome and low serum testosterone.
4 Decrease in body hair and skin alterations Some early interventional studies in hypogonadal men have shown beneficial effects on improving
5. Decreased bone mineral density resuliing in osteopenia and osteoporosis obesity, lipid profile and glycaemic control. However. in the recent past, the lnternational Society for
6. lncrease in visceral fat the Study o{ the Ageing Male (ISSAM) recommended caution in thc use of testosterone replacement
in patients with significant cai'diovascular risk factors. Until the results of ongoing long term studies
Not all of these manifestations need to be present for the diagnosis to be ttiade. Further- become available, the utility of testosterone replacement to improve metabolic profrle in hypogonadal
more, some manifestations may be more prominent than others in individual patients. men is not proven.

Blood investigations Prior to commencing therapy, the following should first be estalished:
Diagnosis is mJe when clinical manifestations of LoH are supported by biochemistry suggestive
of
1. Serum prostate specific antigen (PSA)
restosterone deficiency. However, there is no current consensus on the serum level of testosterone
specific
2. l-laematocrit (Hct) level
at which a particular patient would be diagnosed with LOH. Furthermore, age and ethnicity
J. Lrver lunctron tesl (L l- I )
reference ranges have also not been fully established. Wide irrter-individlral variation have also been
observed in asymptomatic individuals.
4. Fasting lipid profile

(fi) Thyroid function test should also be done to exclude hypothyroidism which may
1. Total testosterone
mimic or coexist with LOH symptoms.
Testosterone level varies tlrroughout the day as a result o{ the circadian rhythm. The best time
for serum measurement is in the morning from 0700 hours to 1 1 00 hours. Estimation of total
testosterone levels is readily available in most laboratories but results need to be intepreted with
(SHBG) may result
caution. ln the elderly and the obese, elevations of sex hormone binding globulin
in seemingly normal TT levels, despite the patient being hypogonadal (false negative result). However,
in the preience of suggestive LOH symptoms, TT levels below 10 nmol/L may warrant a trial
of
therapy after a discussion of the risks and benefits. With equivocal levels of 1 0-1 5 nmol/l, further
tests are advised.

2. Free testosterone (FT)

Determination oi {ree testosterone levels is useful in patients with low normal or equivocal levels of
TT. Only 0.5 to 3% of circulating testosterone is'free' or unbound. Most are bound to
sex hormone

bindini globulin (SHBG) and albumin. Direct measurement of FT is not readily available in most
laboratories.

AN APPROACH TO LATE.ONgIT HYPOGONADISM (LOH) I AN APPROACH TO COMMON UROTOGICAT DISORDERS 63

62ANAPPRoACHToCoMMoNURoLoGIcALDIsoRoERSIANAPPRoACHToUTE.oNSETHYPoGoNADISM(LoH)
 WHAT ARE THE TREATMENT OPTIONS FOR LOH? SUGGESTED ALGORITHM FOR MANAGEMENT OF LOH

Tabte 1 - Most frequently used tesloslerone preperations

Generic name
lnjectabte Testoslerone cypionate
Testosterone enanthate
Mixed testosterone esters
Trade name Dose Symptoms of L0H
(exc[uded hypothyroidism as a differentiaL cause)
Depo-testosterone cypionate 200-400m9 every 3-4 weeks i.m.
Oetatestryt 200-400m9 every 2-4 weeks i.m.
Testorviron, Testosterone depot
Sustanon 250 250m9 every 3 weeks i.m.

Oral Fluoxymesterone* Hatotestin 5-20m9 daaly Do TotaI testosterone [TT]

Methyltestosterone* Metandren 10-30m9 daity
TPstosterone undecanoate Andriot 120-200m9 daity
Mesterotone Proviron 35-75m9 daily
Vistinon. Vistimon

Subcutaneous Testosterone implants 1 200m9 every 6 months

2.5-7.5m9 daity
NormaITT
Transdermal Testosterone patches Androderm
Testoderm l0-l5mg/daily
Testosterone gel Androgel 5'10q

I 7o atkytated testosterone preparations ftuoxymesterone and methyttestosterone are both assocrated with serious
liver toxicity: i-m., instramuscularty

Do FSH/LH/PRL Do SHBG, a[bumin, calcuLate

Common preparations used locally include:
1. Oral therapy testosterone undecanoate 40 to B0 mg orally two or three times a day
-
2. lntramuscular rnjection - long actrng preparation testosterone undecanoate 1000m9 (Nebido)
every 3 months
3. Topical - testosterone 1 % gel (Androgel) once daily
High FSH/LH, Low TT/FT NorrnaI or low FSH/LH
HOW DO I MONITOR PATIENTS ATTER STARTING TREATMENT FOR LOH? and Low TTIFT, high PRL
1. Monitor PSA and Hct at the {ollowing frequency: at 3 months, then 6 months, and then yearly
if the results are normal
2. LFT and Fasting lipids at the following frequency: 6 mths. then yearly if normal

WHEN IS A REFERRAL TO THE UROLOGIST INDICATED ? Start reptacement therapy lnvestigate pituitary Seek other causes
1. Low normal/ low FSH and LH levels, which are suspicious for hypogonadotrophic hypogonadism.
This may be due to a pituitary cause for low serum testosterone levels
2. Raised PSA or abnormal digital rectal exam which may suggest prostate cancer REFERENCES
3. Symptoms suggestive of srgnificant BPH which may worsen during testosterone replacement 1. "lnvestigation, treatment and monitoring of late-onset hypogonadism in males
4- Poor response to initial testosterone therapy - Official Recommendations of The lnternational Society for The Study of the Ageing Male
(SSAM)".A. Morales and B. Lunefeld. The Aging Male 2002;5:74-86
2. Singapore Urological Association * 6uidelines on Late Onset Hypogonadisr-l
3. Urology and the Family Physician Ed M Wonq and Foo KT.

64 AN APPRoACHTocoMMoN URotoGIcALDISoRDER5 I AN APPROACH TO UTE-ONSET HYFOGONADISM (LOH}

AN APPROACH TO LATE.ONSET HYPOGONADISM (LOH) I AN APPROACH TO COMMON UROTOGICAL DIsORD€RS 65
 AI'I APPROAGH TO IAIE ONSET IIYPOGONADISM IN MEN: 14 AN APPROACH TO RENAL CYSTS
A FAMII.V PHYSIGIAN'S PERSPEGIII'E Dr Kenneth Chen
Resident, Depaftment of Urology, Singapore General Hospital '

A,/Professor Goh Lee Gan

DrAllen Sim Soon Phang
Professorial Fellow, Division of Family Medicine,
Registrar, Department of Urology, Singapore General Hospital
Ll niversity Medi ci ne Clu ster NU H S.
DrTan Yeh Hong
INTRODUCTION Senior Consultant, Depafiment of Urology, Singapore General Hospital

The approachto late onset hypogonadism (LOH) in men consists of recognising the condition, work
up, and management. WHAT ARE RENAL CYSTS?
Renal cysts are fluid-filled structures in the kidney that are not continuous with the nephron or collecting
RECOGNITION system. They can occur in a variety of diseases in adults and children. With the advent and availability
o{ imaging in modern medrcine, the incidental finding of renal cysts is a common occurrence in the
The triad of sexual symptoms, identified by the European Male Aqeing Study (EMAS)(1), is useful:
outpatient setting. Renal cysls may arise in 3 most common scenarios: incidental simple cysts, autosomal
. Decreased frequency of morninq erectlon,
dominant polycystic kidney disease and acquired cystic disease in patients with end-stage renal disease
. Decreased frequency of sexual thoughts, and on dialysis. Regardless of the setting, the primary clinical concern is accurately distinguishing simple
. Erectiledysfunction. renal cysts from complex renal cysts that may harbour neoplastic masses.

LOH patients may alsc present with less specific symptoms: decreased vitality, decreased mood, WHAT ARE 'SIMPI-E RENAL CYSTS'?
decreased muscle mass and strength.

WORK UP
History - The history workup needs to consider the differential diagnosis:
. Erectile dysfunction - this could be due to hypogonadism alone; be part of a metabolic
syndrome e.g , diabetes mellitus, hypertension, obesity; or a harbinger of cardiovascular
disease; smoking and stress also result in erectile dysfunction.
. Weight loss and sarcopenia - Exclude other reasons besides hypogonadism.
n Mood changes, lethargy, and weakness - Exclude depression.
. Statin therapy * This can result in low testosterone and hypogonar:lism (2).

physical examination - Conduct a general examination, cardiovascular examination, and

examination of the male genitalla.

MANAGEMENT
Do total testosterone (TI) as the initial screening investigation and manage according! (3) :

Figure 1. Sipple right renal cyst (arrowed)

o lf TT is above 12 nmol/|, no testosterone (T) supplementation is required;
. lf TT is less than 8 nmol/l repeat test to confirm and measure LH and FSH Simple renal cysts are the most common type of renal cysts. The majority of which are
* if results show low T. high LH and high FSH - exclude contraindications, initiate T diagnosed incidentally in asymptomatic patients, for example in thg"workup for asymptomatic
supplementation and monitor accordingly; if results show low T, low-normal LH, FSH - microscopic hematuria or on imaging done to investigate other non-related symptoms.
investigate pituitary and other causes and manage accordingly.
. l{ TT is between 8-12 nmol/l - repeat TT with SHBG to calculate free T - and if f ree T is less than The aetiology of simple cysts is not fully known but does not appear to have a genetic predisposition.
225 pmolll (65 pq/ml) give T supplementation; above this no T supplementation required. However the incidence increases with age and so does the size of the cysts (1). They usually do not
cause symptoms but when they do, pain is the most common presenting complaint especially in
REFERENICES larqe sizeable renal cysts, which may cause pressure and mass effect. One may also develop fever and
tenderness in the flanks if the cyst becomes infected.
1. Wu A, Beynon lM, Pye SR, Silman AJ, Finn JD, O'Neill TW et al.; EMAS Group'
FC, Tajar
ldentification of late-onset hypogonadism in middle-aged and elderly men. N Engl J Med. 2010 HOW ARE SIMPLE RENAL CYSTS DIAGNOSED?
Jul 8;363(2):123-35.
As mentioned. the majority of patients with simple renal cysts are discovered incidentally on imaginq
2. Corona G, Boddi V, Balercia G, Rastrelli G, De Vita G, Sforza A, Forti G. Mannucci E, Maggi M'
done for other reasons (e.g. ultrasound (US) scan of the abdomen for hepatitis B surveillance, computed
The effect of statin therapy cn testosterone tevels in subjects consulting for erectile dysfunction.
tomography (CT) scarr of the abdomen for abdominai symptoms).
J Sex Med. 2010 Apr;7(4 Pt 1):1547-56.

. 3. Lunenfeld B, Arver S, Moncada l. Rees DA, Schulte HM. How to help the aging male? Current
approaches to hypogonadism in primary care. Aging Male. 201 2 Dec;15(4):1al-91 '

I AN APPROACH TO UTE.ONSET HYPOGONADISM (LOH) ANAPPROACHTORENALCYSTS IANAPPROACHTOCOMMONUROLOGICALDISORDERS 67

AN APPROACH TO COMN]ON UROLOGICAL DISORDERS
 WHAT I5 ACQUIRED CYSTIC KIDNEY DISEASE? Polycystic kidney disease (PKD) is an inherited genetic disorder characterised by the growth
of
numerous cysts in the kldneys. lt predominantly affects the kidneys but may involve other organs;
strch the liver and pancreas. The number of cysts and the urrmistakable involvement of otherloroans
help to distinguish this entity from simple renal cysts or acquired cystic kidney disease. About haif
of
the affected patients go on to develop end-stage renal failure (E5RF) (g,9) The term polycystc kidney
disease is reserved for one of the two hereditary conditjons:

ADU !-T POI-YCYSTXC K!DNIEY DISEASE

Adult polycystic kidney disease, also known as autosomal dominant polycystic kidney disease is th€ most
common inherited [orm. About g0 percent of all pKD cases are autosomal dominani pKD. symptoms
usually develop between the ages of 30 and 40 years, hence the term adult, but they could occur
earlietl even in childhoodl0. lt is estimated that less than half of these cases will be iiaqnosed during
a
patients lifetime, as they are often clinically silent.

I^IOW TO DIAGNJOSE AD!,J[-T PO!.YCYSTIC KIDNEY DOSEASE?

The diagrrosis is easy to establsh in patients with symptomatic disease who have a family history
of ADPKD. ln such patients, the diagnosis is certain with the finding of large kidneys wlt'h multiple
bilateral cysts on ultrasonography or CT sranning. The specific nr-llber ofiysts p"i kldn"y detected
by
Figure 2. Acquired cystic kidney disease (arrowed) ultrasonography that would establish the diagnosis of ADpKD depends upon patients, age.

Patients with end-stage renal disease on dialysis form a specific population at risk for development
of multiple renal cysts. The incidence of acquired cystic kidney disease increases with the duration
of dialysis (2.3). lt is well reported in the literature that the risk of developing renal cell carcinoma
increases dramatically in patients with acquired cystic kidney disease (3-7), hence many of these
patients are on surveillance imaging by the renal physicians.
Affected patients may present with flank pain or renal insufficiency, and hypertension. Cysts may
alscr
be seen in the liver and pancreas. Hepatrc cysts, tor example, can be detected in over iralf
of the
cases and ai'e more ccmmonly seerr in women and in patients over 40 years of age (g). Additional
manifestations rnay include intracranial arreurysms, decreased urinary concentrating ability, and
abdominal wall hernias (1 1).

HOW IS ACQUIRED CYSTIC KIDNEY DISEASE DIAGhIOSED?

ln the outpatient primary healthcare setling, one may occasionally encounter a patient with end-
stage renal disease on dralysis presenting with abdominal pain or fever Acquired cystic kidney disease
with possible complications should be considered. An ultrasound of the kidneys is a reasonable
screening tool. The finding of any suspicious cyst (keeping in mind the elevated risk o{ renal cell
carcinoma in this subset of patients) or cystic complications such as infection or hemorrhage should
prompt a referral to the urologist.

WHAT I5 POLYCYSTIC KIDNEY DISEASE?

I-igure 4. Polycystic kidneys on CT scan

ln up to 25 per cent o{ patients, both clinical presentation and imaginq would suggest a diagnosis of
ADPKD, but there is no family history of the entity. The majority of these cases arelnherited, and it is
most likely that the affected parent has passed away without a formal diagnosis. lt is also possible
that
the parent has a subclinical form of disease not clinically apparent yet. ln a very small percentage of
patients. it may be trLlly a sporadic new mutation.

It{ FANITI[.E POLYCYSTIC K!DNEY DISEASE

lnfantile polycystic kidney disease is a rare form, inherited via an autosomal recessive pattern, hence also
Figure 3. Adult polycystic krdney disease with known as autosomal recessive polycystic kidney disease. Symptoms of autosomal recessive pKD begin
multiple cysts in both kidneys and the liver. in the earliest months of life, even in the wonrb. up to 50% of affected neonates die of pulmonary
hypoplasra, the result of oligohydramnios from severe intrauterine kidney disease. Those who survive
the
neonatal period invariably progress to end-stage renal disease by early adulthcoC.

58 AN AppRoACH To coMMoN uRoLocrcAt DtsoRDERs I AN AppRoAcH To RENAL cysrs AN APPROACH TO NENAL CYSTS I AN APPROACH TO COMMON UROLOGICAI. DISORDERS 59
 Management is largely conservative in nature and patients are usually given anti-inflammatory analgesia
The two most common organs involved are the kidney and the liver. The kidneys are increased in size
and a course of antibiotics to prevent infection from setting in. As haemorrhagic cysts resolve, they
with muhiple microcysts. The severity of the renal disease is proportional to the number of nephrons
develop residuai calcification in a central pattern or within the cyst wall that becomes thickened and
affected by the cysts. This entity is always associated with some degree o{ congenital hepatic fibrosis
develop septae with the cyst becoming multilocular or multilobulac essentially acquiring the features of
(1 2). Over time, hepatomegaly and portal hypertension ensue in most patients.
a complex cyst.

HOW TO DIAGNOSE INFANTILE POLYCYSTIC KIDNEY DISEASE? lnfection

With the development of antenatal ultrasonography, most cases of ARPKD are detected prenatally. In
severe cases, ARPKD can be detected after 24 weeks of gestation by antenatal ultrasonography, which
shows markedly enlargecl kidneys with increased echogenicity but no visible cysts. These changes may
be accompanied by oligohydramnios and the absence of urine in the fetal bladder These infants may
die early in life from pulmonary insu{ficiency secondary to pulmonary hypoplasia, with or without the
Potter syndrome. Less severe cases may not be detected by antenatal checks'
The diaqnosis of ARPKD rs typically based upon clinical, imaging, and laboratory findings. ln some
cases, when a diagnosis remains uncertain, molecular genetic testing may establish the diagnosis.
WHAT IS THE MANAGEMENT OF RENAL CYSTS?
perhaps the first distinction that must be inade at the primary health care settinq is whether the
patient presents symptomatically or asymptomatically. Asympiomatic cases will usually be uncovered
Secondary infection of cysts occurs in 2.5o/o of cases, and can result from either haematogenous
spreadof bacteria or {rom local extension from infected renal parenchyma or collecting system. The
typical clinical presentation includes pain, leukocytosis, and fever. Pain caused by infected cysts can
be severe enough to mimic an acute abdomen. lnfected cysts are initially managed like an abscess by
percutaneous drainage and intravenous antjbiotics. Cyst aspiration can also be used to determine if a
cyst is infected or not. lf infected, cyst drainage is valuable because some antibiotics do not penetrate
into cyst fluid even when the cyst wall is inflamed. The aspirate can also be cultured to direct antibiotic
therapy.
Table 1. Bosniak Classification of Renal Cysts
Bosniak Radiological Featureg Risk of
Ctassification Malignancy

as incidental findings on ultrasound or CT performed to evaluate other conditions. The management Simpte cyst with hairtine thin watL
of cysts is guided by the Bosniak classification (Table 1 ). lndeed, not all renal cysts have to be No septa, catcification or solid components
referred to the urologists. The management of symptomatic patients is however different and larqely No enhancement, water consistency

depends on the cause for their symptoms. These patients may present with complications from I Septar few hairLine thin, no measureable enhancement
the renal cyst such as infection, hemorrhage or rupture and witl often need to be treated at the Catcification: fine or short segment may be present in wat[ or septa
Unifo.mty high attenuating cysts l.3cml that are welt marginated and
tertiary setting. Apart frorn becoming symptomatic, cysts that develop complications may acquire non-enhancing are inctuded-
radiological features that mimic malignancy and require careful evaluation and follow-up. One must Generatly welt marginated
also be rnindful to screen the family menrbers upon the possible diagnosis of inherited polycystic
kidney disease. ilF Septa: muttipLe thin hairlino, no enhancement
Minimat thickening of watl or septa which may contain calcification that may be
thick and nodutai no measureable enhancement
WHAT ARE THE COMPLICATIONS OF REIIIAL CYSTS? Totatty intrarenaL high attenuating non-enhancing rencI tesions >3cm are included

Complications are rare with a reported range of 2 to 4%. The principal complicatiorrs are ilt Measurabte enhancement 40-60./"
hemorrhage, infection, or rupture. Such cases in general should be refered for further evaluation lndeterminate Cystic mass with thickened smooth or irregutar watts or septa with
measurabte enhancement
and treatment (1 3).
Ctearty matignant cystic lesions that have alt of the features oflll with enhancing B5-100%
Pain Matignanl soft tissue components adjacent to but independent of the watt or septa
pain is the most common symptom associated with renai cysts and probably results from distention
c,f the renal capsule, but may also be a secondary effect due to obstruction of the collecting system.
Oral analgesia can be prescribed if no contraindications.

Obstruction
Cysts cause some degree o{ collecting system obstruction in certain cases. Parapelvic cysts may
obstruct the ureter o; low pelvis, whereas peripheral cortical cysts can cause infundibular or calyceal
obstruction. lf there is any eviclence of obstructive uropathy, the patient should be re{erred for
furttter treatment.

Rupture
Cyit rupture can be a source of significant pain. Rupture can occur due to blunt trauma or increased
intracystic pressure in the setting of intracystic hemorrhage or infection. Haematuria is seen in
up to 80% of patients with cyst rupture, likely resulting from cyst rupture into an adjacent calyx.
Less commonly, cysts can rupture through the renal capsule and cause a perirenal urinoma or
haematoma.

liaemorrhage
Haemorrhage may occur in a pre-exlsting simple cyst, or a cyst may form from the liquefaction of
a traumatic haemorrhage within the kidney parenchyma. Approximately 6% of simple cysts are
complicated by haemorrhage, usually as a result of trauma, enlargement, or bleeding diathesis.

AN APPROACH TO RENAI CYSTS I AN APPROACII TO COMMON UROTOGICAL DISORDERS 71

t0 AN APPROACH TO COMN]OIi UROLOCICAT DISORDERS I AN APPROACH TO RTNAL CYSTS
 The presence of true contrast enhancement of the lesion (a minimum increased attenuation of 1 0 to
'15 Hounsfield units) is
the most important characteristic separating categories lll and lV which are
'100 percent.
associated with malignancy in 40 to from the categories l, ll, and llF, which are typically
benign processes (14).

Figure 7. Bosniak ll Cyst (arrow indicates internal septations)

CATEGORY gIF

Category llF cysts deserve follow-up imaging (hence the "F") to document stability. A tollow-up
ultrasourrd can be clone in \/hich the absence of change supports benign disease. while progressron
raises suspicion oi a neoplastic process. in which case, a cr Kidneys can be done to confirm the
findings. When foilouring Lrp a patient for a Bosni.:k llF cyst, it is important to obtain prior studies for
purposes of comparison. lf such studies are unavailable, an additionai imaging stutiy shoLtld be ordered
for f urther characterisation.
Frgure 5. Bosniak Classification

CATEGORY IAND II
Further evaluation of Bosniak category I and ll lesions is generally not required. However, in certain
instances, repeat Lrltrasonography at 6 to 1 2 months to assure

Figure 8. Bosniak llF Cyst (arrows indicate thickened septae)

CATEGORY iUI

The management of Bosniak category lll lesions is controversial. Some authorities recommend that all
Bosniak category lll lesions undergo surgical evaluation, given the high incidence of malignancy (40 to
60 percent) with these findings. ln addition, if the radiologist is unable to clearly distinguish a caiegory
Figure 6. Bosniak I Cyst (arrowed)
llF {rom a lll lesion, it should be placed in a higher category, particularly if a partial nephrectomy is
anatomically possible.

72 ANAPPROACH ToCoMMoN I}RoIoGIcAI DISoRDFRS I AN APPROACH TO RENAT CYSTS AN APPROACH TO RENAL CYSTS I AN APPROACH TO COMMON UROLOGICAT DISORDERS 7
 on the other hand, there would be a significant number of unnecessary operations with such an REFERETICES
approach, since a signi{icant percentage of patients with indeterminate iesions have benign lesions.
1. Lippert, MC, Renal Cystic Disease, Adult and Pediatric Urology, 4th ed, Gillenwater, lY, Grayhack,
JT, Howards, SS, Mitchell, N/E (Eds), Lippincott, Williams & Wilkins, Philadelphia, 2002, pp. 8589
we may offer the patient two additional modalities, CT Kidneys and Contrast-
To avoid this situation,
enhanced Ultrasound of the kidneys. 2. lshikawa l. Acquired cystic disease: mechanisms and manifestations. Semin Nephrol 1991;11:671.
3. Matson MA et al. Acquired cystic kidney disease: occurrence, prevalence, and renal cancers.
..:::Br ,-.{ ' 1;
Medicine (Baltimore) 1990: 69:217.
4w'
4. Kojima Y et al. Renal cell carcinoma in dialysis patients: a single center experience. lnt J Urol 2006;
ll 1 3:1 045.

I 5. Farivar-Mohseni, H et al. Renal cell carcinoma and end stage renal disease. I Urol. 2006 175-2018.
6. Chandhoke PS et al. Acquired cystic drsease of the kidney: a management dilemma. J Urol 1992;
147:969.
7. Denton MD et al. Prevalence of renal cell carcinoma in patients wlth ESRD pre-transplantation: a
pathologic analysis. Kidney Int 2002; 61 2201.
8. Bae KT et al. Magnetic resonance rmaging evaluatron of hepatic cysts in early autosomal-dominant
polycystic kidney disease: the Consortium for Radiologic lmaging Studies of Polycystic Kidney
Disease cohort. Clin J Am Soc Nephrol 2ooq 1:64.
9. Patel V et al. Advances in the pathogenesis and treatment of polycystic kidney disease. Curr opin
Nephrol Hypertens 2009; 18:99.
10. Wilson PD. Polycystic krdney disease. N Engl J Med. Jan 8 2004;350(2):151-64.
1'1 . Pirson Y. Extrarenal Manifestations of Autosomal Dominant Polycystic Kidney Disease. Adv Chronic
Kidney Dis. Mar 201 0;1 7(2): 1 73-1 80.
12. Gunay-Aygun M et al. Autosomal recessive polycystic kidney disease and congenital hepatic
fibrosis: summary statement of a first National lnstitutes of Health/Office of Rare Diseases
conference. I Pediatr. Aug 2006;'149(2):1 59-64.

Figure 9. Bosniak lll Cyst (arro$/ indicates enhancing septa)

1 3. Eknoyan G. A clinical view of simple and complex renal cysts. Journal of the American Society of
Nephrology. 2009;20: 1 87 4.

CATEGORY [V 14. lsrael Glvl et al. Urology. 2005 Sep;66(3):484-8.

Category lV lesions invariably require surqery, wrth appfoxrmately 85 to 100 percent being
1 5. Curry NS et al. Cystic renal masses: accurate Bosniak classification requires adequate renal Cl AJR
Am J Roentgenol. 2000:1 75(2):339.
malignant'l 5-1 7. These lesions should be treated as malignant entities and be investigated
accc,rdingly with staging CT. chest x-ray and bone scan if necessary.
1 6. Bosniak MA. The small (less than or equal to 3.0 cm) renal parenchymal tumor: detection,
diagnosis, and controversies. Radiology. 1991:179(2):307.
1 7. Bosniak N4A. Tlre current radiological approach to renal cysts. Radiology. 1 986;1 58( 1 ): 1 .

Fiqure 1 0. Bosniak lV Cyst (arrow indicates enhancing soft tissue)

AN APPROACH TO COMMON UROLOGICAL DISORDERS I AN APPROACH TO RENAL CYSTS AN APPROACH TO RENAL CY5T5 I AN APPROA'H TO IJROTOG AL DISORDERS 75
'OMMON
 '1.
Diagram Suggested flowchart {or management of Renal Cysts
RENAL CYSTS: A FAMIIY PHYSICIAN'S PERSPEGIIUE
Dr Hwang SiewWai
Director & Family Physician, Consultant, SingHealth Potyctinics - Bukit Merah
The majority of renal cysts encountered in the polyclinic come from incidental findings of
imaging studies, such as during annual ultrasound surveillance of the liver in chronic Hepatitis B. These
patients are generally well with an unremarkable history and physical examination
but 'red flag' symptoms o{ fever, werght loss, haematuria or flank pain should be enquired for.

The Bosniak classification has been mentioned as a useful guide to the need for further evaluation of
a renal cyst. This classification, however, is based upon CT findings (such as the presence of contrast
enhancement irom the lesion) and may have limited usefulness in the polyclinic as the diaqnosis of a
renal cyst in the polyclinic setting is frequently based on ultrasonic examination (that is typically not
contrast enhanced).

Simple cysts are most commonly found. On ultrasonography, simple cysts appear well defined
wrth a spherical or ovoid shape and possess a thin smooth wall distinct from the surrounding renal
parenchyma. There is no septum or calcification within these cysts. Sound waves are well transmitted
and internal echoes are absent.

ln clinical practice. patients with simple cysts can be reassured that no fllrther investigation or treatmenl
is requireci. lt is good practice to pre-empt patients to seek medical attention in the rare event of fever,
flank pain, abdominal pain or haematurra- Another option is to repeat an ultrasouncl examination in 6
months to ensure that there is no change in size or consistency of thls cyst. This ultrasound scan can be
ordered dii'ectly bv the polyclinic doctor.

I would refer patients with large cysts (size greater than 3cm) or complex cysts to a urologist
to exclude the possibility of malignancy,. Features o{ complex cysts include calcification, multi-loculation,
thickened walls or thickened septa.

Diagram 2. Suggested follow-up according to Bosniak Classification

76 AN AppRoAcH To coMMoN uRoloctcal DtsoRDtRs I AN appRoAcH To RENAL cysrs AN APPROACH TO RENAI. CYSIS I AN APPROACH TO COMMON UROLOGICAL DISORDERS 7i
 15 AN APPROAG}I TO THE EUATUATION OF GOMMON
SGROTAL GONDITIONS
Dr Lee Fang Jann
Consultant, Department of Urology, Singapore General Hospital
HOW DO IAPPROACH SCROTAL SWELLINGS?
Scrotal swellings can range from benign congenital conditions to malignancies and surgical
emergencies. A good history and physical examination, together with an understanding of the scrotal
anatomy helps accurately differentiate most lesions.
TESTES
Torsion
Torsion of the testicle is a disease process whereby there is cessation of blood to the testicle due to a
twisting of the testicular artery (and associated structures). Testicular torsion occurs most frequently
between the ages of 1 0 and 30, with a peak at the age of 1 3 to 1 5 years, but any age group may be
affected. The left side rs affected more often than the right. Torsion of both testes can occur in 27o
o{ boys.
The classical presentaticn is one of acute pain and swelling in the ipsilateral hemiscrotum waking the
patient from sleep. There may be referred pain to the lower abdomen. Nausea and vomiting may
accompany the painful condition. Unnary symptoms such as dysuria and urgency are usually absent.
lf the patient permits physical examination, one will find a firm testicle riding high in the scrotum
with an abnormal trarrsverse lie (1).'l-he cremasieric reflex is usually absent and elevation of the
testicle aggravates the Pain (2).
This is a surgical emergency as the testicular salvage rates depends on the duration of ischemia, with
a 9O7o salvage rate within the first 6 hours. This drops to 500/o after 12 hours, and to only 10% after
24 hoirrs (3-5).
lf the clinical suspicion is high, immediate surgical exploration is mandatory. Doppler ultrasound and
testicular radionuclide scanning to assess blood flow to the testicle may be offered to patients in
equivocal cases if they can be obtained in a timely manner.
Surgery consist of surgical detorsion and bilateral orchidopexy. A gangrenous testicle will have to
be removed. Leaving a non-viable testicle in-situ puts the patient at risk of developing subsequent
orchalqia, infectiorr and leads to the theoretical risk of production of antisperm antibodies as the
blood-testis barrier is broken down.
Torsion o{ the appendix testis usually presents similarly to testicular torsion. lf examination is
performed early in the course before edema sets in, one will be able to feel a smalltender lump at
the superior pole of the testicle. A blue dot sign may be seen through the scrotal skin, corresponding
to the ischemic appendage.
The treatment consists of supportive care with nonsteroidal analgesia atld rest. ln uncertain cases,
exploration is recommended to rule out testicular torsion.
Testicular Cancer
Testicular cancer is the most common cancer rn men age between 5 and 35 years old. lt comprises
'1
1-2% of all male malignancies but causes 127o of cancer death in men between the ages of 20 to
35. Germ cell tumours occur most commonly between the ages of 20 to 40. Lymphoma is more
common over the age of 60. A history of cryptorchidism is a risk factor.
The patient usually presents with a painless scrotal swelling. An episode or trauma may lead to self
examination and detection of the mass. Late stage disease may have associated systemic symptoms
of weight loss and leg swelling.
AN APPROACFI TO COMMON UROLOGICAL DISORDERS I AN APPROACH TO THE EVALUATION OT COMMON SCROTAL CONDITIONS
Clinical examination will reveal a hard to firm, non-tender irregular testicular mass. Adjacent structures
such as the sperrnatic cord and scrotal skin may be involved. Systemic examination may reveal
lynrphadenopathy and gynaecomastia.
Scrotal ultrasound is the first line investigation to confirm the diagnosis. A CT of the abdomen and chest
is crucial for staging. Serum tumour markers such as beta-hunlan chorionic gonadotrophin and alpha-
fetoprotern help to prognosticate risk. lt is also useful for follow-up in selected tumour subtypes.
An <irchiectomy is therapeutic in localized disease, and histology will confirm the tumour subtype.
Additional adjuvant chemotherapy or radiation therapy may be required. A high cure rate of 95% is
possible with low stage cancer.
EPIDIDYMIS
Epididymitis/Epididymo-orchitis
The condition is most common in the young adult. lt may or may not be related to a prior sexual
encounter. The pain and swelling is usually indolent in onset but may be difficult to differentiate from
torsion. A history of urinary tract infection, urinary catheterization or urinary tract surgery should be
sought. The offensive pathogens are usually bacterial. Chlamydia trachomatis and Neisseria gonorrhea
should be considered rn the sexually active patient.
On physical examination, localised epididymal or generalized scrotal tenderness may be elicited. The
cremasteric reflex is usually present. Urinalysis will show pyuria and a urine sample should be collecied
for culture.
A Doppler ultrasound will demonstrate increased blow flow in the affected testes. The treatment
consists of scrotal elevation, analgesia and a course of broad spectrum antibiotics. Fluoroquinolones are
advantageous as they have a good penetratron of the urinary tract. A two weeks course of doxycycline
should be adrninistered concurrently in those suspected with C. trachomatis infection. The partner
should also be treated in view of a high risk of cross-infection.
Spermatocele
This is a sperrn-contarning retention cyst rn the epididymis. lt is usually painless and presents as a self
detected nodule in the head of the epididymis. Ihis can be felt above. behrnd and separate from the
testis. lt does not transilluminate. They are most common in men above the age of forty.
Spermatocelectomy can be offered to those with bothersome symptoms. This should be delayed if
preservation of fertility is important .
Pampiniform plexus
A varicocele refers to abrnormal enlargement of the veins draining the testis. Most varicoceles are
diagnosed in the teens or early adulthood. They rarely develop after the age of 40 years. They occur in
'I 5% of males. Causes of varicoceles
lnclude incompetent valves ang[ proximal venous obstruction. They
occur more frequently on the left sjde.
The typical presentation is a dull, dragging ache in the affected scrotum. The symptom increases over
the course of the day and is exacerbated by exertion. Physical examination will reveal a "bag of worms"
around the spermatic cord that disappears when the patient is supine.
The diagnosis can be confirmed on scrotal ultrasound. Varicocelectomy should be offered to
symptomatic individuals, and those with the sequelae of testicular atrophy or subfertility.
SPERMATIC CORD
Hydrocele
A hydrocele is a collection of fluid around the testis or spermatic cord. lt is caused by fluid secretion
from the tunica vaginalis that envelopes the testis. lt occurs in 1 % of males. Hydrocele can also be
reactive and secondary to a trauma, inflammation or tumout
AN APPROACH TO THE EVALUATION OF COMMON SCROTAL CONDITIONS I AN APPROACH TO COMMON UROLOGICAT DISORDTRS 79
 The patient usually presentswith painless swelling of the scrotum. There will be a smooth scrotal
swelling on examination that prevents palpation of the testicle within. Transillumination will usually
clinch the diagnosis and one can get above the mass.

An ultrasound will exclude any underlying testicular pathology. Simple asptratron will afford
temporary relief, but re-accummulation of the {luid is common, as the tunica vaginalis produces
0.5mls o{ fluid per day. A more definite treatment consists o{ open hydrocelectomy and allowinq fluid
reabsorption by the scrotal lymphatics.

lnguinal hernia
A persistent processus vaginalis may lead to an indirect inguinal hernia. The hernia foliows the path
of the processus vaginalis through the inguinal canal into the scrotum. This leads to a presentation
with an indirect inquinal hernia.

The typical presentation is an rnguinal or scrotal swelling that fluctuates in size. Physical exertions
or Valsalva maneuvers ygill exacerbate the swelling, while resting in a supine position makes it less
obvious.

Physical examination may reveal an inguinal-scrotal mass that can be felt separate from the normal
scrotal contents. The hernia can often be reduced unless it is incarcerated.
Strangulated hernias will be painful and examinatlon will demonstrate tenderness. There may be
associated nausea, vomiting and lower abdominal pain in keeping with bowel obstruction and
in{arction. This represents a surgrcal emergency and the need for urgent repair.

Algorithm for diagnosing scrotal swelling by anatomy

Tender and diffusely

swollen- acute onset

REFEREI{CES
1. Kadish, H.A. and R.G. Bolte, A retrospective review of pediatric patients with epididymitis,
testicular torsion, and torsion of testicular appendages. Pediatrics, 1 998. 1 02(1 Pt 1 ): p. 73-6.
2. Rabinowitz, R., The importance of the cremasteric reflex in aLute scrotal swelling in children. .l

Urol, 1984. 132(1): p.89-90.

3. Ringdahl, E. and L. Teague. Testicular torsion. Am Fam Physician, 2006. 74(10): p.1739-43.
4. Prater,i.M. and B.S. Overdorf. Testicular torsion: a surgical emergency. Anr Fam Physician, '1991.
44(3): p. 834-40.
Granados, E.A., P Caicedo, and J.M. Garat, [Testicular torsion aiter 12 hours. lll]. Arch Esp Urol,
1998. 51(10): p. 978-81.

AN APPROACH TO THE EVALUATION OF COMMON SCROTAL CONDITIONS AN APPROACH TO COMMON UROLOGICAL DIsORDERS
80 AN APPROACH TO COMMON UROLOGICAL DISORDERS I AN APPROACH TO THE EVALUATION OT COMMON SCROTAT CONDITIONS I
 The patient usually presents with painless swelling of the scrotum. There will be a smooth scrotal
swellinq on examinatjon that prevents palpation of the testicle within. Transillumination will usually
clinclr the diagnosis and one can get above the rnass.

An ultrasound will exclude any underlying testicular pathology. Simple aspiration will afford
temporary relief, but re-accummulation of the fluid is common, as the tunica vaglnalis produces
0.5mls olfluid per day. A more definite treatment consists of open hydrocelectomy and allowing fluid
reabsorption by the scrotal lymphatlcs.

lnguinal hernia
A persistenr processus vaginalis may lead to an indirect rnguinal hernia. The hernla follows the path
of the processus vaginalis through the inguinal canal into the scrotum. This leads to a presentatiol.)
with an indirect inguinal hernla.

The typical presentation is an inguinal or scrotal swelling that fluctuates in size. Physical exertions
or Valsalva maneuvers will exacerbate the swelling, while resting in a supine position makes it less
obvious.

physical examination may reveal an inguinal-scrotal mass ihat can be felt separate from the normal
scrotal contents. Tlre hernia can often be reduced unless it is incarcerated
Strangulated hernias will be painful and examination will demonstrate tenderness. There may be
associated nausea, vomiting and lower abdorninal pain in keeping with trowel obstruction and
infarction. This represents a surgical enlergency and the need for urgent repair'

Algorithm for diagnosing scrotal swelling by anatomy

Tender and diffusely

swollen, acute onsei

REFERENCES
1. Kadish, H.A. and R.G. Bolte, A retrospecttve review of pediatflt patients with epididymitis.
testicular tolsion, and torsion of testicular appendages. pediatrics, 1 999. 1 02( 1 pt i ): p. 73-6.
2. Rabinowitz, R., The importance of the cremasteric reflex in acute scrotal swelling in children. J

Urol, 1984. 132(1): p 89-90.

3. Ringdahl, E. and L. Teague, Tesricular torsion. Am Fam physician,2006.74(10): p. 1739-43.
4. Prater, J.M. and B.S. Overdorf, Testicular torsion: a surgical emergency. Am Fam physician, .1991
44(3): p.834-40.
5. Granados, E.A., P Caicedo, and J.M. Garat, [Teslicular torsion after '12 hours. lll]. Arch Esp Urol.
1998. 51(10): p. 978-81.

AN APPROACH TO THE TVAIUATION OF COMMON SCROTAL CONDITIONS IANAPPROACIITOCOMMONUROLOGICALDISORDERS

AN APPROACH TO COMMON UROLOGICAL DISORDER5 I AN APPROACH TO THE EVALUATION OF COMMON SCROIAL CONDITIONS 81
 Ail M
GOMMON SGROTAL GONDIflONS:
APPROAGH 16 AHTAND REAI LIFE GIJrurcAt PRASTICE
A FAMITY PHYSIGIAN'S PERSPEGTIVE Professor Foo KeonE Tatt
Emeritus Consultant, Department of Urolagy, Singapore General Hospital
Dl Farhad Fakhrudin Vasanwala
Family Physician, Consi,uttant, Department of Family Medicine and Continuing Care,
S i ng apore Gen eral H o s pital DOING A PAINTING IS SIMILAR TO REAL I-IFE CI-IhIICAI- PRACTICE
Doing a painting
TESTICULAR EXAMINATION Firstly, you need to be observant of the details, and yet, you need to see the whole picture. Then, based

Men from puberty onwards should examine monthly their testes after a hot shower or bath, when on the fundampntal principles of a good composition and perspective, the artist would prioritrze the
the scrotum is loose (1) and while standing (2). They should first examine each testicle separately, details accordingly, so as to produce a pleasing composition. lt is not possrble or desrrabie to include all
feeling for lumps and then compare them to see whether one is larger than the other. Testicular the details, and the artist needs to prioritize what is important and what is so, in order to give a goocl
pain can be referred from the abdomen or radlcular pain from thoracolumbar spine. notably a di;c balance to the art piece.
disruptionattheTl2-11 level involvingtheLl root(3).Considerdissectinganeurysminanolder
persorr presenting as a testicular torsion (3). ln real life clinical practice
4 Firstly, the clinician needs to consolidate the evidence and facts that he has accrued from clinical

TORSION
Torsion of the testes is the most common cause of scrotal pain in infancy and childhood (3). Torsion
of the testes should form part of the di{ferential diagnosis in a boy or young man who is vomitlng
and has intense parn in the lower abdominal quadrant inguinal region (3).Suspect self-correcting
testicular torsion in repeated episodes of severe spontaneous pain.
Refer [or orchidopexy (3).
EPIDIDYMO-ORCH!TI5
The clinical picture of epididymo-orchitis can mimic torsion of the testes so closely', in most children;
the diagnosis should be made orr surgical exploration (4). Patients who fail to respond to treatment
{or epididymo-orchitis should be reassessed {or abscess formation or testicular cancer (3).
TESTICULAR CANCER
The development of an acute hydrocele should be regarded with suspicion (3). Beware of the
strangulated inguinoscrotal hernia presenting as a testicular torsion (3). Men with a history of
testicular cancer should be educated to watch for symptoms of cardiac disease and reduce their
risk through lifestyle modification. Chemotherapy recipients are also at a higher risk of leukemia,
secondary non germ-cell tumours, including lun9, biliary, gastrointestinal, bladder, and stomach
cancers. and sarcomas. Thus patients must be counseled on these risks and go for regular periodic
health checks. They should also be counselled not to ignore any red flags pertinent to these
conditions (5).
REFERENCES
evaluation of the patient (from history, physical examination and investigations). This needs to be
integrated with background information from the literature.
Secondly, he needs to see the whole picture, based on his understanding of the pathology and natural
hrstory of diseases, and to predict the future course of events for that particular patient.
Thirdly, he would need to balance the risks and benefits of treatment, so as to achieve balanced and
cost-effective management- all done in the best interest of the patient.
Therefore, in ihe process of formulating clinical guidelines for practicing clinicians, althouqh there is a
need to gather all published evidence, it is not necessary to include all the details. It would be ttre job
of the committee to decide what is more important and what is less so. lrrhich. in effect, would be to
prioritize information. l'his would be based on both the dccuracy and the practicality of the tests or
parameters available. For example, digital rectal examination (DRE) with ultrasound (trarrs-abdonrinal
or trans-rectal) can easily and preciseiy evaluate patients with lower urinary tract symptoms. lt can
also diagnose clinical benign prostatic hyperplasia and assess the prostate volume. Although magnetic
resonance imaging may offer more accuracy. it would not be practical rn real life practice due to cost
and logistics issues.
Hence, usrng trans-abdominal ultrasound to assess the size and the shape of the prostate (ie. intravesical
prostatic protrusion-lPP) would be practical for most urologists. This would be a more balanced
approach as trarrs-abdominal ultrasound is rron-invasive (compared to the
trans-rectai route), and easy to perform. The IPP is no1 only diagnostic but also predictive of the severity
and rate of progression of bladder outlet obstruction.

1. Testicular Cancer Self Examination. fhe lnstitute of Cancer Research. At \mw.everyman-

Thus, clinical practice is not entirely confined to scientific evidence and pathophysiology, but also
campaign.org/Iesticular-Cancer/Iesticular-cancer-self-examination involves the art of prioritizing the iacts, and placing them in correct perspective. Treating the disease is
2. Testicular self-examination. U.S. Department of Heahh and Human Services National lnstitutes the science, but in real life clinical practice, treatrng the patient, is an Art. Just as in a scientific journal,
of Heallh. http://www.nlm.nih. gov/medlinepluyency/article/003909.htm the statistical significance is the science, but determining the clinical significance for an individual patient
3. MurtaghsGeneralPractice5thEdition,20ll MccrawHill is an Art. That would be based not only on our knowledge (evidence based medicine) but also on our
4. Hutson J. Beasley S, Woodward A. Jones'Clinical Paediatric Surgery. Oxford: Blackwell Scientific experience and a balanced perspective; all done inthe patients best interest at heart.
Publications. 2003: I 85-8.
Wampler 5, Llanes M. Common Scrotal and Testicular Problems. Primary Care: Clinics in O{fice REFERENCE
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82 AN APPRoACII To coMMoN URoLoGIcAL DISoRDER5 I AN APPXOACH TO THE EVALUATION OT COMMON SCROTAL CONDITIONS ART AND REAL LIFE CLINICAI PRACTICE IANAPPROACHTO COMMON UROLOGICALD|SORDERS 8