Managing Urge Incontinence

Urge incontinence is a condition where urine leakage occurs involuntarily, often preceded by a sudden urge to urinate. According to NICE guidance on Urinary incontinence (CG171), women with urge incontinence or mixed incontinence should be offered bladder training as a first-line treatment for at least six weeks. This involves learning techniques to control the urge to urinate and gradually increasing the time between visits to the toilet. If bladder training is not effective, immediate release oxybutynin may be offered as an alternative treatment.

Haemodialysis units must remain vigilant against blood-borne viruses, despite following standard infection control measures, in order to safeguard both patients and healthcare staff. Fortunately, the occurrence of hepatitis B outbreaks associated with dialysis units has significantly decreased over the past three decades. The Department of Health recommends immunisation against Pneumococcus, influenza, and Hepatitis B for individuals with chronic kidney disease, including those undergoing haemodialysis. While vaccination schedules for both children and adults are rapidly evolving, healthcare professionals must stay informed of these changes and be aware of recommendations for special groups. Although the administration of vaccinations is often delegated, general practitioners must be knowledgeable about contraindications and schedules to provide guidance to patients and parents. Conducting audits of specific target groups may reveal a need for catch-up immunisation in light of changing recommendations.

The Department of Health recommends that people over the age of 65 and those with certain medical conditions receive an annual influenza vaccination. These medical conditions include chronic respiratory disease, chronic heart disease, chronic kidney disease, chronic liver disease, chronic neurological disease, diabetes mellitus, immunosuppression, asplenia or splenic dysfunction, and pregnancy. Additionally, health and social care staff, those living in long-stay residential care homes, and carers of the elderly or disabled may also be considered for vaccination at the discretion of their GP.

The pneumococcal polysaccharide vaccine is recommended for all adults over the age of 65 and those with certain medical conditions. These medical conditions include asplenia or splenic dysfunction, chronic respiratory disease, chronic heart disease, chronic kidney disease, chronic liver disease, diabetes mellitus, immunosuppression, cochlear implants, and patients with cerebrospinal fluid leaks. Asthma is only included if it requires the use of oral steroids at a dose sufficient to act as a significant immunosuppressant. Controlled hypertension is not an indication for vaccination.

The Controversy Surrounding PSA Testing for Prostate Cancer

The introduction of the prostate-specific antigen (PSA) test has led to increased awareness and earlier diagnosis of prostate cancer. However, the use of PSA testing for screening purposes remains controversial. While PSA is currently the best method for detecting localized prostate cancer and monitoring treatment response, it lacks specificity as it is also increased in patients with benign prostatic hypertrophy. Additionally, the effectiveness and cost-effectiveness of treating localized cancer is still uncertain.

Bone scans at diagnosis are likely unnecessary for patients with a PSA below 20 ng/ml, as bone metastases are unlikely at this level. Repeated bone scans during treatment are also unnecessary unless there are clinical indications, as repeated PSA tests are just as effective and more cost-effective. Biopsies under transrectal-ultrasound control are now commonly used for diagnosing prostate cancer, with a PSA exceeding 4 ng/ml being the usual indication for biopsy.

PSA is a protease produced exclusively by epithelial prostatic cells, both benign and malignant. It breaks down the high molecular weight protein of the seminal coagulum, resulting in more liquid semen. PSA testing is also useful for monitoring therapy in patients with prostate cancer.

Overall, the lack of specificity of the PSA test, combined with a lack of knowledge about the epidemiology and natural history of prostate cancer, are reasons against instituting a national screening program.

Understanding Laboratory Findings in Renal Failure

Renal failure can be caused by various underlying conditions, and laboratory findings can help identify the specific cause. Bence-Jones proteinuria, the excretion of immunoglobulin light chains, is indicative of multiple myeloma. Other symptoms such as fatigue, breathlessness, and back pain can further support this diagnosis. Anaemia is a common occurrence in renal failure due to decreased erythropoietin production and marrow suppression. Hyperuricaemia, on the other hand, is not associated with any particular underlying cause. Hypocalcaemia is also common in renal failure, but it is typically secondary to decreased renal synthesis of calcitriol and doesn’t indicate a specific cause. Metabolic acidosis occurs in renal failure due to decreased renal acid excretion, but it alone doesn’t help differentiate between potential causes. Understanding these laboratory findings can aid in the diagnosis and management of renal failure.

Factors Affecting Prostate-Specific Antigen Blood Test

The prostate-specific antigen (PSA) blood test is a common diagnostic tool used to detect prostate cancer. However, the test results can be influenced by various factors, including benign prostatic hypertrophy, prostatitis, urinary retention, urinary tract infection, old age, urethral or rectal instrumentation/examination, recent vigorous exercise, or ejaculation.

It is important to note that the PSA test should be deferred for at least a month in individuals with a proven urinary tract infection. Additionally, if the person has recently ejaculated or exercised vigorously in the past 48 hours, the test should also be postponed. While some sources suggest delaying PSA testing for at least a week after a digital rectal examination, studies have shown that rectal examination has minimal impact on PSA levels.

In summary, several factors can affect the results of the PSA blood test, and it is crucial to consider these factors before interpreting the test results accurately.

Understanding Renal Function: Estimating Glomerular Filtration Rate

Renal function is a crucial aspect of overall health, and it is typically measured by estimating the glomerular filtration rate (GFR). There are various equations available to calculate GFR, but the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation is recommended by NICE. This equation takes into account serum creatinine, age, gender, and race.

It is important to note that laboratories often assume a standard body surface area, which can lead to inaccurate results in individuals with extreme muscle mass. For example, bodybuilders, amputees, and those with muscle wasting disorders may have an overestimated or underestimated GFR.

Additionally, certain factors can affect serum creatinine levels and thus impact the accuracy of eGFR results. For instance, consuming a cooked meat meal can temporarily increase serum creatinine concentration, leading to a falsely lowered eGFR. Conversely, strict and long-term vegetarians may have a reduced baseline eGFR.

If an eGFR result is less than 60 ml/min/1.73m2 in someone who has not been previously tested, it is recommended to confirm the result by repeating the test in two weeks.

Finally, it is worth noting that creatinine clearance is sometimes used as a rough measurement of GFR, but it has limitations. This method involves a 24-hour urine collection and a serum creatinine measurement during that time period. However, accurate urine collection can be challenging, and this method tends to overestimate GFR and is time-consuming.

Overall, understanding how to estimate GFR and interpret the results is crucial for assessing renal function and identifying potential health concerns.

Patients who have recently started treatment are commonly affected by neuroleptic malignant syndrome, which can lead to renal failure due to rhabdomyolysis.

Neuroleptic malignant syndrome is a rare but serious condition that can occur in patients taking antipsychotic medication or dopaminergic drugs for Parkinson’s disease. It can also occur with atypical antipsychotics. The exact cause of this condition is unknown, but it is believed that dopamine blockade induced by antipsychotics triggers massive glutamate release, leading to neurotoxicity and muscle damage. Symptoms typically appear within hours to days of starting an antipsychotic and include fever, muscle rigidity, autonomic lability, and agitated delirium with confusion. A raised creatine kinase is present in most cases, and acute kidney injury may develop in severe cases.

Management of neuroleptic malignant syndrome involves stopping the antipsychotic medication and transferring the patient to a medical ward or intensive care unit. IV fluids are given to prevent renal failure, and dantrolene may be useful in selected cases. Dantrolene works by decreasing excitation-contraction coupling in skeletal muscle by binding to the ryanodine receptor and decreasing the release of calcium from the sarcoplasmic reticulum. Bromocriptine, a dopamine agonist, may also be used. It is important to note that neuroleptic malignant syndrome is different from serotonin syndrome, although both conditions can cause a raised creatine kinase.

Chronic kidney disease (CKD) patients often require more than two drugs to manage hypertension. The first-line treatment is ACE inhibitors, which are especially effective in proteinuric renal disease like diabetic nephropathy. However, these drugs can reduce filtration pressure, leading to a slight decrease in glomerular filtration pressure (GFR) and an increase in creatinine. NICE guidelines state that a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable, but any increase should prompt careful monitoring and exclusion of other causes. If the rise is greater than this, it may indicate underlying renovascular disease.

Furosemide is a useful Antihypertensive drug for CKD patients, particularly when the GFR falls below 45 ml/min*. It also helps to lower serum potassium levels. However, high doses are usually required, and if the patient is at risk of dehydration (e.g. due to gastroenteritis), the drug should be temporarily stopped. The NKF K/DOQI guidelines suggest a lower cut-off of less than 30 ml/min.

Understanding Varicocele: Symptoms, Diagnosis, and Management

A varicocele is a condition characterized by the abnormal enlargement of the veins in the testicles. Although it is usually asymptomatic, it can be a cause for concern as it is associated with infertility. Varicoceles are more commonly found on the left side of the testicles, with over 80% of cases occurring on this side. The condition is often described as a bag of worms due to the appearance of the affected veins.

Diagnosis of varicocele is typically done through ultrasound with Doppler studies. This allows doctors to visualize the affected veins and determine the extent of the condition. While varicoceles are usually managed conservatively, surgery may be required in cases where the patient experiences pain. However, there is ongoing debate regarding the effectiveness of surgery in treating infertility associated with varicocele.

In summary, varicocele is a condition that affects the veins in the testicles and can lead to infertility. It is commonly found on the left side and is diagnosed through ultrasound with Doppler studies. While conservative management is usually recommended, surgery may be necessary in some cases. However, the effectiveness of surgery in treating infertility is still a topic of debate.

Understanding Nephrotic Syndrome and Nephritic Syndrome

Nephrotic syndrome is a condition characterized by proteinuria, hypoalbuminemia, edema, and hyperlipidemia. On the other hand, nephritic syndrome is defined by azotemia, hematuria, hypertension, and oliguria. Both syndromes present with edema, but the amount of proteinuria is higher in nephrotic syndrome.

In nephrotic syndrome, the glomerulus has small pores that allow protein to pass through but not cells, resulting in proteinuria and hypoalbuminemia. The liver compensates for protein loss by increasing the synthesis of albumin, LDL, VLDL, and lipoprotein(a), leading to lipid abnormalities. Patients with nephrotic syndrome are also at risk of hypercoagulability and infection due to the loss of inhibitors of coagulation and immunoglobulins in the urine.

The etiology of nephrotic syndrome varies depending on age and comorbidities. Minimal change disease is the most common cause in children, while focal segmental glomerulosclerosis is the most common cause in younger adults. Membranous nephropathy is the most common cause in older people, and diabetic nephropathy in adults with long-standing diabetes. Secondary causes include amyloidosis, lupus nephritis, and multiple myeloma.

Categorizing glomerular renal disease into syndromes such as nephrotic syndrome and nephritic syndrome helps narrow the differential diagnosis. Understanding the differences between these two syndromes is crucial in the diagnosis and management of glomerular renal disease.

The patient is most likely suffering from prostate cancer. Despite having well-controlled BPH with medication, he has developed new lower urinary tract symptoms along with red flag features such as weight loss and back pain. Although his PSA levels are normal, it should be noted that he is taking finasteride which can lower PSA levels. The duration of symptoms and weight loss over a period of 3 months are not indicative of a urinary tract infection. It is also unlikely that the patient is suffering from treatment-resistant BPH after successfully managing the condition for 5 years. While spinal cord compression can cause urinary symptoms, it is unlikely to cause nocturia or flow issues.

Benign prostatic hyperplasia (BPH) is a common condition that affects older men, with around 50% of 50-year-old men showing evidence of BPH and 30% experiencing symptoms. The risk of BPH increases with age, with around 80% of 80-year-old men having evidence of the condition. Ethnicity also plays a role, with black men having a higher risk than white or Asian men. BPH typically presents with lower urinary tract symptoms (LUTS), which can be categorised into obstructive (voiding) symptoms and irritative (storage) symptoms. Complications of BPH can include urinary tract infections, retention, and obstructive uropathy.

Assessment of BPH may involve dipstick urine testing, U&Es, and PSA testing if obstructive symptoms are present or if the patient is concerned about prostate cancer. A urinary frequency-volume chart and the International Prostate Symptom Score (IPSS) can also be used to assess the severity of LUTS and their impact on quality of life. Management options for BPH include watchful waiting, alpha-1 antagonists, 5 alpha-reductase inhibitors, combination therapy, and surgery. Alpha-1 antagonists are considered first-line for moderate-to-severe voiding symptoms and can improve symptoms in around 70% of men, but may cause adverse effects such as dizziness and dry mouth. 5 alpha-reductase inhibitors may slow disease progression and reduce prostate volume, but can cause adverse effects such as erectile dysfunction and reduced libido. Combination therapy may be used for bothersome moderate-to-severe voiding symptoms and prostatic enlargement. Antimuscarinic drugs may be tried for persistent storage symptoms. Surgery, such as transurethral resection of the prostate (TURP), may also be an option.

It is important to document the full name and role of a chaperone when they are used during an intimate or intrusive examination. The chaperone should be impartial and not related to the patient. Patients are allowed to express a preference for the gender of the chaperone. During the examination, it is recommended that the GP only speaks if necessary.

GMC Guidelines on Intimate Examinations and Chaperones

The General Medical Council (GMC) has provided comprehensive guidance on how to conduct intimate examinations and the role of chaperones in the process. Intimate examinations refer to any procedure that a patient may consider intrusive or intimate, such as examinations of the genitalia, rectum, and breasts. Before performing such an examination, doctors must obtain informed consent from the patient, explaining the procedure, its purpose, and the extent of exposure required. During the examination, doctors should only speak if necessary, and patients have the right to stop the examination at any point.

Chaperones are impartial individuals who offer support to patients during intimate examinations and observe the procedure to ensure that it is conducted professionally. They should be healthcare workers who have no relation to the patient or doctor, and their full name and role should be documented in the medical records. Patients may also wish to have family members present for support, but they cannot act as chaperones as they are not impartial. Doctors should not feel pressured to perform an examination without a chaperone if they are uncomfortable doing so. In such cases, they should refer the patient to a colleague who is comfortable with the examination.

It is not mandatory to have a chaperone present during an intimate examination, and patients may refuse one. However, the offer and refusal of a chaperone should be documented in the medical records. If a patient makes any allegations against the doctor regarding the examination, the chaperone can be called upon as a witness. In cases where a patient refuses a chaperone, doctors should explain the reasons for offering one and refer the patient to another service if necessary. The GMC guidelines aim to ensure that intimate examinations are conducted with sensitivity, respect, and professionalism, while also protecting the interests of both patients and doctors.

First-line treatment for benign prostatic hyperplasia involves the use of alpha-1 antagonists.

Benign prostatic hyperplasia (BPH) is a common condition that affects older men, with around 50% of 50-year-old men showing evidence of BPH and 30% experiencing symptoms. The risk of BPH increases with age, with around 80% of 80-year-old men having evidence of the condition. Ethnicity also plays a role, with black men having a higher risk than white or Asian men. BPH typically presents with lower urinary tract symptoms (LUTS), which can be categorised into obstructive (voiding) symptoms and irritative (storage) symptoms. Complications of BPH can include urinary tract infections, retention, and obstructive uropathy.

Assessment of BPH may involve dipstick urine testing, U&Es, and PSA testing if obstructive symptoms are present or if the patient is concerned about prostate cancer. A urinary frequency-volume chart and the International Prostate Symptom Score (IPSS) can also be used to assess the severity of LUTS and their impact on quality of life. Management options for BPH include watchful waiting, alpha-1 antagonists, 5 alpha-reductase inhibitors, combination therapy, and surgery. Alpha-1 antagonists are considered first-line for moderate-to-severe voiding symptoms and can improve symptoms in around 70% of men, but may cause adverse effects such as dizziness and dry mouth. 5 alpha-reductase inhibitors may slow disease progression and reduce prostate volume, but can cause adverse effects such as erectile dysfunction and reduced libido. Combination therapy may be used for bothersome moderate-to-severe voiding symptoms and prostatic enlargement. Antimuscarinic drugs may be tried for persistent storage symptoms. Surgery, such as transurethral resection of the prostate (TURP), may also be an option.

Semen analysis is a test that requires a man to abstain from sexual activity for at least 3 days but no more than 5 days before providing a sample to the lab. It is important that the sample is delivered to the lab within 1 hour of collection. The results of the test are compared to normal values, which include a semen volume of more than 1.5 ml, a pH level of greater than 7.2, a sperm concentration of over 15 million per ml, a morphology of more than 4% normal forms, a motility of over 32% progressive motility, and a vitality of over 58% live spermatozoa. It is important to note that different reference ranges may exist, but these values are based on the NICE 2013 guidelines.

The risk of arrhythmias can be increased by all antiarrhythmic drugs, especially when hypokalaemia is present.

Amiodarone is a medication used to treat various types of abnormal heart rhythms. It works by blocking potassium channels, which prolongs the action potential and helps to regulate the heartbeat. However, it also has other effects, such as blocking sodium channels. Amiodarone has a very long half-life, which means that loading doses are often necessary. It should ideally be given into central veins to avoid thrombophlebitis. Amiodarone can cause proarrhythmic effects due to lengthening of the QT interval and can interact with other drugs commonly used at the same time. Long-term use of amiodarone can lead to various adverse effects, including thyroid dysfunction, corneal deposits, pulmonary fibrosis/pneumonitis, liver fibrosis/hepatitis, peripheral neuropathy, myopathy, photosensitivity, a ‘slate-grey’ appearance, thrombophlebitis, injection site reactions, and bradycardia. Patients taking amiodarone should be monitored regularly with tests such as TFT, LFT, U&E, and CXR.

Possible Causes of Poor Urinary Stream in Boys

Poor urinary stream in boys can be a sign of urinary-tract obstruction, which is often caused by posterior urethral valves. While this condition is usually diagnosed before birth, delayed presentation can be due to recurrent urinary tract infections. Other possible causes of poor urinary stream include urethral stricture, bladder calculi, and neurogenic bladder. However, these conditions are less common and may be associated with other developmental or neurological issues. Vesicoureteric reflux, which occurs when urine flows back from the bladder up the ureters, may also be a result of urinary tract obstruction but is not likely to be the primary cause of poor urinary stream and terminal dribbling.

Finasteride: A 5-alpha-reductase Inhibitor

Finasteride is a medication that inhibits the enzyme 5-alpha-reductase, which is responsible for converting testosterone to dihydrotestosterone (DHT). By blocking this conversion, finasteride opposes the effects of testosterone, leading to common side effects such as gynaecomastia and reduced libido.

In addition to its use as a treatment for these side effects, finasteride is also prescribed orally as Propecia to treat male pattern hair loss. Despite its potential side effects, finasteride has been shown to be an effective treatment for hair loss in many men.

According to NICE guidelines, men who exhibit symptoms of a lower UTI should be treated with oral antibiotics like trimethoprim or nitrofurantoin for 7 days, without the need for referral to urology unless the infection is recurrent. Waiting for the results of urinary microscopy culture and sensitivity is not recommended, as prompt treatment is necessary to prevent further complications. Intravenous antibiotics are not usually required unless the patient shows signs of fever, riggers, chills, vomiting, or confusion. In this case, the patient’s borderline temperature doesn’t warrant hospital admission, and empirical antibiotics should be administered. While it is important to rule out sexually transmitted infections, the patient’s symptoms suggest a UTI, and there is no indication of an STI in his medical history.

Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. Lower UTIs are more common and can be managed with antibiotics. For non-pregnant women, local antibiotic guidelines should be followed, and a urine culture should be sent if they are aged over 65 years or have visible or non-visible haematuria. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. Pregnant women with symptoms should have a urine culture sent, and first-line treatment is nitrofurantoin, while amoxicillin or cefalexin can be used as second-line treatment. Asymptomatic bacteriuria in pregnant women should also be treated with antibiotics. Men with UTIs should be offered antibiotics for seven days, and a urine culture should be sent before starting treatment. Catheterised patients should not be treated for asymptomatic bacteria, but if they are symptomatic, a seven-day course of antibiotics should be given, and the catheter should be removed or changed if it has been in place for more than seven days. For patients with signs of acute pyelonephritis, hospital admission should be considered, and local antibiotic guidelines should be followed. The BNF recommends a broad-spectrum cephalosporin or a quinolone for 10-14 days for non-pregnant women.

Possible Causes of Renal Dysfunction in a Patient with Chronic Headache

One possible cause of renal dysfunction in a patient with chronic headache is analgesic nephropathy. This condition is characterized by polyuria, haematuria, deteriorating renal function, hypertension, and anaemia, which can result from long-term use of over-the-counter analgesics. Another possible cause is acute glomerulonephritis, which can present with asymptomatic proteinuria, haematuria, or nephrotic or nephritic syndrome. However, the patient’s history is more suggestive of analgesic nephropathy. Renal failure secondary to sepsis is unlikely, as the patient has no symptoms of sepsis and the urine culture is negative. Hypertensive renal disease usually presents with asymptomatic microalbuminuria and deteriorating renal function in patients with a long history of hypertension, which doesn’t fit with the clinic history given above. Reflux nephropathy, which commonly occurs in children due to a posterior urethral valve or in adults due to bladder outlet obstruction, is not suggested by the above history.

Renal Failure and its Effects on Electrolyte Balance

Renal failure can lead to metabolic acidosis due to decreased excretion of H+ ions and reduced synthesis of urinary buffers such as phosphate and ammonia. This results in a marked decrease in urinary phosphate levels and a rise in extracellular potassium levels due to intracellular displacement. Calcium homeostasis is also affected as the kidney’s role in activating vitamin D and increasing calcium reabsorption from the kidneys is inhibited by phosphate retention. Sodium levels may be normal or decreased due to water retention outweighing the decreased excretion. Overall, renal failure has significant effects on electrolyte balance.

To diagnose CKD in a patient with an eGFR <60, it is necessary to measure the creatinine level in the blood, obtain an early morning urine sample for ACR testing, and dip the urine for haematuria. CKD is confirmed when these tests show a persistent reduction in kidney function or the presence of proteinuria (ACR) for at least three months. Proteinuria is a significant risk factor for cardiovascular disease and mortality, and an early morning urine sample is preferred for ACR analysis. The patient should provide another blood sample after 90 days to confirm the diagnosis of CKD. Chronic kidney disease is often without symptoms and is typically identified through abnormal urea and electrolyte levels. However, some individuals with advanced, undetected disease may experience symptoms. These symptoms may include swelling in the ankles, weight gain, increased urination, fatigue, itching due to uraemia, loss of appetite leading to weight loss, difficulty sleeping, nausea and vomiting, and high blood pressure.

When a pregnant woman presents with symptoms of a UTI such as dysuria, frequency, and malaise, nitrofurantoin is the first-line treatment option. However, if the woman is close to term, this medication should be avoided. A urine culture should be sent and if necessary, second-line antibiotics such as amoxicillin or cefalexin can be used. For non-pregnant women, trimethoprim or nitrofurantoin are the recommended treatments. In cases of acute pyelonephritis, IV cefuroxime is a viable antibiotic option.

Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. Lower UTIs are more common and can be managed with antibiotics. For non-pregnant women, local antibiotic guidelines should be followed, and a urine culture should be sent if they are aged over 65 years or have visible or non-visible haematuria. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. Pregnant women with symptoms should have a urine culture sent, and first-line treatment is nitrofurantoin, while amoxicillin or cefalexin can be used as second-line treatment. Asymptomatic bacteriuria in pregnant women should also be treated with antibiotics. Men with UTIs should be offered antibiotics for seven days, and a urine culture should be sent before starting treatment. Catheterised patients should not be treated for asymptomatic bacteria, but if they are symptomatic, a seven-day course of antibiotics should be given, and the catheter should be removed or changed if it has been in place for more than seven days. For patients with signs of acute pyelonephritis, hospital admission should be considered, and local antibiotic guidelines should be followed. The BNF recommends a broad-spectrum cephalosporin or a quinolone for 10-14 days for non-pregnant women.

Understanding the Causes of Membranous Glomerulonephritis

Membranous glomerulonephritis is a kidney disease that often presents with a mixed nephrotic and nephritic picture. The condition is characterized by widespread thickening of the glomerular basement membrane, and its cause is often unknown. However, certain factors have been linked to the development of membranous glomerulonephritis, including cancers of the lung and bowel, infections such as hepatitis and malaria, and drugs like penicillamine and non-steroidal anti-inflammatory drugs.

One of the most significant risk factors for membranous glomerulonephritis is malignancy, which is responsible for approximately 5-10% of cases. Patients over the age of 60 are at higher risk, and effective treatment of the underlying malignancy can sometimes lead to improvement in renal symptoms. However, spontaneous recovery occurs in about one-third of patients, while one-third remain with membranous nephropathy and one-third progress to end-stage renal failure.

Other conditions, such as chronic obstructive pulmonary disease (COPD), hepatic fibrosis, hypercholesterolemia, and hypertension, can also impact renal function but do not directly cause membranous glomerulonephritis. COPD, for example, can induce microvascular damage, albuminuria, and a worsening of renal function, while hepatic fibrosis can lead to hepatorenal syndrome. Chronic hypertension can also lead to hardening of the arteries and a reduction in renal function. However, understanding the specific causes and risk factors for membranous glomerulonephritis is crucial for effective diagnosis and treatment.

To ensure proper catheterisation, it is important to push the catheter in as far as it can go before inflating the balloon, once urine flow has been achieved. Aseptic technique should always be used to reduce the risk of infection. It is not advisable to use force to overcome resistance during catheter insertion, as this can create a false passage. The smallest catheter size that allows for effective drainage should be used, unless there is an infection or postoperative bleeding, in which case a larger bore may be necessary to minimise obstruction risk. For long-term catheterisation, an indwelling Foley catheter with an inflatable balloon should be used instead of a straight (Nelaton) catheter that is immediately removed.

For patients with proteinuria (ACR > 70 mg/mmol), the goal for blood pressure treatment is to keep it below 130/80 mmHg. In cases of chronic kidney disease (CKD), where the patient has a high Cr level and ACR, the aim is to keep systolic BP below 140 mmHg and diastolic BP below 90 mmHg. However, for patients with CKD and diabetes, or an ACR of > 70 mg/mmol, the target is slightly lower, with systolic BP below 130 mmHg and diastolic BP below 80 mmHg.

Contrary to popular belief, ACE inhibitors are not contraindicated for patients with only one kidney. In fact, patients with a single kidney are more prone to renal impairment and should be considered for ACE-inhibitor treatment.

While it was previously recommended that patients with proteinuria consume a high-protein diet to replace urinary losses, recent studies have shown that a low-protein diet can reduce the death rate in those with CKD. However, a prescribed/modified protein intake of 0.75 g/kg ideal-bodyweight/day for patients with stage 4–5 CKD not on dialysis, and 1.2 g/kg ideal-bodyweight/day for patients treated with dialysis, is now suggested.

It is important to note that the result measured by laboratories is an estimated glomerular filtration rate (eGFR), which assumes standard body surface area and race. Patients who have had amputations or other physical differences could receive inaccurate results. Additionally, an eGFR level of between 60 and 89 ml/min can signify kidney disease if proteinuria is also present, as is the case with this patient who has an ACR level of > 70 mg/mol. Therefore, it would be inappropriate to suggest that an eGFR level above 60 ml/minute per 1.73 m2 indicates the absence of renal impairment.

NICE guidelines advise against the routine treatment of asymptomatic bacteriuria in catheterised patients. Treatment should only be given if the patient is experiencing symptoms. In such cases, a 7-day course of antibiotics may be prescribed, and the catheter may be changed if necessary. However, removal of the catheter is not an option for long-term catheterised patients. If sepsis is suspected, the patient should be referred to a hospital for intravenous antibiotics.

Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. Lower UTIs are more common and can be managed with antibiotics. For non-pregnant women, local antibiotic guidelines should be followed, and a urine culture should be sent if they are aged over 65 years or have visible or non-visible haematuria. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. Pregnant women with symptoms should have a urine culture sent, and first-line treatment is nitrofurantoin, while amoxicillin or cefalexin can be used as second-line treatment. Asymptomatic bacteriuria in pregnant women should also be treated with antibiotics. Men with UTIs should be offered antibiotics for seven days, and a urine culture should be sent before starting treatment. Catheterised patients should not be treated for asymptomatic bacteria, but if they are symptomatic, a seven-day course of antibiotics should be given, and the catheter should be removed or changed if it has been in place for more than seven days. For patients with signs of acute pyelonephritis, hospital admission should be considered, and local antibiotic guidelines should be followed. The BNF recommends a broad-spectrum cephalosporin or a quinolone for 10-14 days for non-pregnant women.

Urgent Referral Pathway for Suspected Testicular Cancer

Any painless enlargement of the testis should be referred urgently to urology for investigation of testicular cancer. The patient should be seen within 2 weeks, and an ultrasound should be arranged urgently. While serum alpha-fetoprotein (AFP) is a tumour marker associated with testicular cancer, it should not be used alone to exclude a tumour. AFP can also be used in staging. A mid-stream specimen of urine (MSU) is not necessary unless there are urinary symptoms or signs of infection. Antibiotics are not indicated for painless swelling without signs of infection or epididymo-orchitis. While prompt investigation is necessary, urgent urological admission is not required unless the patient is acutely unwell.

Side Effects of Commonly Used Medications

Nephrotic syndrome is a condition characterized by proteinuria, oedema, hyperlipidaemia, and hypoalbuminaemia. It can be caused by various primary and secondary glomerular diseases, as well as certain drugs. Some drugs that can cause nephrotic syndrome include non-steroidal anti-inflammatory drugs, captopril, lithium, gold, diamorphine, interferon alfa, penicillamine, and probenecid.

Gold, specifically sodium aurothiomalate, is used to treat active progressive rheumatoid arthritis. However, it can cause immune complex nephritis, leading to unexplained proteinuria above 300 mg/l, and blood dyscrasias and gastrointestinal bleeding.

Chloroquine is associated with several side effects, such as visual disturbances, skin reactions, nausea and vomiting, hepatitis, and abdominal pain. However, nephrotic syndrome and renal impairment are not known complications.

Methotrexate can cause various blood dyscrasias and liver toxicity, but nephropathy is a rare complication.

Paracetamol, when used in its oral form, has rare side effects. However, overdose can lead to liver damage, but kidney damage is infrequent.

Prednisolone is associated with numerous side effects, including anxiety, abnormal behavior, cataracts, cognitive impairment, Cushing syndrome, hypertension, increased risk of infection, and weight gain. Renal complications are not commonly associated with prednisolone use.

In summary, while these medications can be effective in treating certain conditions, it is important to be aware of their potential side effects and to monitor for any adverse reactions.

Iatrogenic Causes of Gynaecomastia: The Role of Gonadorelin Injections

There are various iatrogenic causes of gynaecomastia that healthcare providers should consider when evaluating a patient with this condition. In this case, the culprit behind the breast enlargement is the gonadorelin injections.

Gonadorelin analogues initially stimulate the release of luteinising hormone (LH) by the pituitary gland. However, in the early stages of treatment, this can cause a tumour flare, which can lead to complications such as spinal cord compression and ureteric obstruction. To prevent this problem, an anti-androgen may be prescribed alongside the gonadorelin injections.

Once treatment is established, gonadorelin analogues produce a clinical picture similar to menopause in females and orchidectomy in males. This occurs as continued use results in hypogonadism due to negative feedback. Typical clinical features include hot flashes, sweating, sexual dysfunction, and gynaecomastia.

Referral for Pelvic Floor Exercises

Referral for supervised pelvic floor exercises is recommended for women who experience urinary stress incontinence after making lifestyle changes. This referral can be made to a continence advisor, specialist nurse, or physiotherapist. The program is tailored to the individual’s needs and lasts for at least three months, with the option to continue if benefits are observed. Patients are advised to perform a minimum of eight pelvic floor muscle contractions three times a day.

It is important to be aware of the evidence-based approach to inform patients of what they may expect in secondary care. For more information on pelvic floor exercises, visit pogp.csp.org.uk.