Conservative management of ureteric stones may involve the use of medical expulsive therapy (MET), which can be achieved through the administration of either an alpha-blocker or a calcium-channel blocker. This treatment aims to facilitate the natural passage of the stone during the observation period.

Research has shown that in adults, both alpha-blockers and calcium channel blockers have been effective in improving the passage of distal ureteric stones that are less than 10 mm in size, when compared to no treatment. Additionally, alpha-blockers have shown to be more effective than placebo in promoting stone passage. Alpha-blockers have also demonstrated more benefits than calcium channel blockers in terms of stone passage, as well as some advantages in terms of hospital stay and pain management. However, there was no significant difference in the time it took for the stone to pass or the overall quality of life.

Currently, the National Institute for Health and Care Excellence (NICE) recommends alpha-blockers as the preferred choice for medical expulsive therapy. For more detailed information, you can refer to the NICE guidelines on the assessment and management of renal and ureteric stones.

Balanitis is the inflammation of the glans, which is the end of the penis. It often occurs alongside inflammation of the foreskin. Balanitis is a common condition that can affect individuals of any age. However, it is most commonly seen in boys under the age of four who have not undergone circumcision. The main symptoms include redness, irritation, and soreness of the glans. In some cases, it may be difficult to retract the foreskin, and there may be discomfort during urination.

There are various factors that can cause balanitis. These include poor hygiene, a non-retractile foreskin condition called phimosis, dermatological conditions like psoriasis, infections such as candidal infection, and allergies. In most cases, balanitis can be diagnosed based on clinical examination. However, if there is uncertainty, a swab may be taken for further investigation.

Treatment for balanitis involves practicing good hygiene and gently cleaning the affected area. If a candidal infection is suspected, clotrimazole may be used. Additionally, a mild steroid cream is often prescribed to reduce inflammation. In cases where recurrent balanitis is caused by phimosis, circumcision may be considered as a potential treatment option.

Renal colic, also known as ureteric colic, refers to a sudden and intense pain in the lower back caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. This condition is commonly associated with the presence of a urinary tract stone.

The main symptoms of renal or ureteric colic include severe abdominal pain on one side, starting in the flank or loin area and radiating to the groin or testicle in men, or to the labia in women. The pain comes and goes in spasms, lasting for minutes to hours, with periods of no pain or a dull ache. Nausea, vomiting, and the presence of blood in the urine are often accompanying symptoms.

The pain experienced during renal or ureteric colic is often described as the most intense pain a person has ever felt, with many women comparing it to the pain of childbirth. Restlessness and an inability to find relief by lying still are common signs, which can help differentiate renal colic from peritonitis. Previous episodes of similar pain may also be reported by the individual. In cases where there is a concomitant urinary infection, fever and sweating may be present. Additionally, the person may complain of painful urination, frequent urination, and straining when the stone reaches the junction between the ureter and the bladder, as the stone irritates the detrusor muscle.

It is important to seek urgent medical attention if certain conditions are met. These include signs of systemic infection or sepsis, such as fever or sweating, or if the person is at a higher risk of acute kidney injury, such as having pre-existing chronic kidney disease, a solitary or transplanted kidney, or suspected bilateral obstructing stones. Hospital admission is also necessary if the person is dehydrated and unable to consume fluids orally due to nausea and/or vomiting. If there is uncertainty regarding the diagnosis, it is recommended to consult further resources, such as the NICE guidelines on the assessment and management of renal and ureteric stones.

Testicular torsion is a condition where the spermatic cord twists, leading to a lack of blood flow to the testis. It is a surgical emergency and prompt action is necessary to save the testis. It is most commonly seen in individuals aged 15-30 years.

Varicocele refers to the presence of varicose veins in the pampiniform plexus of the cord and scrotum. It is more frequently observed in the left testis and may be associated with infertility. This is believed to be due to the increased temperature caused by the varicose veins. Symptoms include a dull ache in the testis, which is often worse after exercise or at the end of the day. Standing examination can reveal the presence of Varicocele. Treatment is usually conservative, with surgery reserved for severe cases.

Hydrocoele can occur at any age and is characterized by the accumulation of fluid in the tunica vaginalis. It presents as scrotal swelling, which can be palpated above. The surface of the hydrocoele is smooth and it can be transilluminated. The testis is contained within the swelling and cannot be felt separately. Primary or secondary causes can lead to hydrocoele, and in adults, an ultrasound is performed to rule out underlying pathology such as tumors. Conservative management is often sufficient unless the hydrocoele is large.

Testicular cancer is the most common cancer in men aged 20-34 years. Awareness campaigns have emphasized the importance of self-examination for early detection. Risk factors include undescended testes, which increase the risk by 10-fold if bilateral. A previous history of testicular cancer carries a 4% risk of developing a second cancer. The usual presentation is a painless lump in the testis, which can also manifest as a secondary hydrocoele. Seminomas account for 60% of cases and are slow-growing, usually confined to the testis upon diagnosis. Stage 1 seminomas have a 98% 5-year survival rate. Teratomas, which can grow faster, make up 40% of cases and can occur within seminomas. Mixed type tumors are treated as teratomas due to their more aggressive nature. Surgical treatment, with or without chemotherapy and radiotherapy, is the primary approach.

Epididymo-orchitis is inflammation of the testis and epididymis caused by infection.

Renal colic, also known as ureteric colic, refers to a sudden and intense pain in the loin area caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. This condition is commonly associated with urinary tract stones. The pain typically starts in the flank or loin and radiates to the labia in women or to the groin or testicle in men.

The pain experienced during renal or ureteric colic is severe and comes in spasms, with periods of no pain or a dull ache in between. It can last for minutes to hours. Nausea, vomiting, and the presence of blood in the urine (haematuria) often accompany the pain. Many individuals describe this pain as the most intense they have ever felt, with some women even comparing it to the pain of childbirth.

People with renal or ureteric colic are restless and unable to find relief by lying still, which helps distinguish this condition from peritonitis. They may have a history of previous episodes and may also present with fever and sweating if there is a concurrent urinary infection. As the stone irritates the detrusor muscle, they may complain of dysuria (painful urination), frequent urination, and straining when the stone reaches the vesicoureteric junction.

To support the diagnosis, it is recommended to perform urine dipstick testing to check for evidence of a urinary tract infection. The presence of blood in the urine can also indicate renal or ureteric colic, although it is not a definitive diagnostic marker. Nitrite and leukocyte esterase in the urine suggest the presence of an infection.

In terms of pain management, non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for adults, children, and young people with suspected renal colic. Intravenous paracetamol can be offered if NSAIDs are contraindicated or not providing sufficient pain relief. Opioids may be considered if both NSAIDs and intravenous paracetamol are contraindicated or not effective. Antispasmodics should not be given to individuals with suspected renal colic.

For more detailed information, refer to the NICE guidelines on the assessment and management of renal and ureteric stones.

A Varicocele is a condition characterized by the presence of varicose veins in the pampiniform plexus of the cord and scrotum. It is more commonly found in the left testis than in the right and may be associated with infertility. The increased temperature caused by the varicosities is believed to be the reason for this. Symptoms include a dull ache in the testis, which tends to worsen after exercise or towards the end of the day. The presence of Varicocele can often be observed during a standing examination. Treatment usually involves conservative measures, although surgery may be necessary in severe cases.

A hydrocoele can occur at any age and is characterized by the accumulation of fluid in the tunica vaginalis. It presents as swelling in the scrotum, which can be palpated above. The surface of the hydrocoele is smooth and it can be transilluminated. The testis is contained within the swelling and cannot be felt separately. Primary or secondary causes can lead to the development of a hydrocoele. In adults, an ultrasound is typically performed to rule out secondary causes, such as an underlying tumor. Conservative management is often sufficient unless the hydrocoele is large.

Testicular cancer is the most common cancer affecting men between the ages of 20 and 34. Recent campaigns have emphasized the importance of self-examination for early detection. Risk factors include undescended testes, which increase the risk by 10 times if bilateral. A previous history of testicular cancer carries a 4% risk of developing a second cancer. The usual presentation is a painless lump in the testis, which can also manifest as a secondary hydrocoele. Approximately 60% of cases are seminomas, which are slow-growing and typically confined to the testis at the time of diagnosis. Stage 1 seminomas have a 98% 5-year survival rate. Teratomas, which can grow more rapidly, account for 40% of cases and can occur alongside seminomas. Mixed type tumors are treated as teratomas due to their higher aggressiveness. Surgical intervention, with or without chemotherapy and radiotherapy, is the primary treatment approach.

Epididymo-orchitis refers to inflammation of the testis and epididymis caused by an infection. The most common viral agent is mumps, while gonococci and coliforms are the most common bacterial agent.

Bladder cancer is the most likely diagnosis in this case, as patients with painless haematuria should undergo cystoscopy to rule out bladder cancer. This procedure is typically done in an outpatient setting as part of a haematuria clinic, using a flexible cystoscope and local anaesthetic.

Prostate cancer is less likely in this case, as the patient’s prostate examination was relatively normal and he only had mild symptoms of bladder outlet obstruction.

Bladder cancer is the seventh most common cancer in the UK, with men being three times more likely to develop it than women. The main risk factors for bladder cancer are increasing age and smoking. Smoking is responsible for about 50% of bladder cancers, as it is believed to be linked to the excretion of aromatic amines and polycyclic aromatic hydrocarbons through the kidneys. Smokers have a 2-6 times higher risk of developing bladder cancer compared to non-smokers.

Painless macroscopic haematuria is the most common symptom in 80-90% of bladder cancer patients. There are usually no abnormalities found during a standard physical examination.

Current recommendations state that the following patients should be urgently referred for a urological assessment: adults over 45 years old with unexplained visible haematuria not caused by a urinary tract infection, adults over 45 years old with visible haematuria that persists or recurs after successful treatment of a urinary tract infection, and adults aged 60 and over with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.

For those aged 60 and over with recurrent or persistent unexplained urinary tract infections, a non-urgent referral for bladder cancer is recommended.

Urinary retention can be caused by various drug classes. One such class is 5α-reductase inhibitors like finasteride, which are prescribed to alleviate obstructive symptoms caused by an enlarged prostate. Some commonly known drugs that can lead to urinary retention include alcohol, anticholinergics, decongestants (such as phenylephrine and pseudoephedrine), disopyramide, antihistamines (like diphenhydramine and phenergan), and amphetamines.

Further Reading:

Urinary retention is the inability to completely or partially empty the bladder. It is commonly seen in elderly males with prostate enlargement and acute retention. Symptoms of acute urinary retention include the inability to void, inability to empty the bladder, overflow incontinence, and suprapubic discomfort. Chronic urinary retention, on the other hand, is typically painless but can lead to complications such as hydronephrosis and renal impairment.

There are various causes of urinary retention, including anatomical factors such as urethral stricture, bladder neck contracture, and prostate enlargement. Functional causes can include neurogenic bladder, neurological diseases like multiple sclerosis and Parkinson’s, and spinal cord injury. Certain drugs can also contribute to urinary retention, such as anticholinergics, opioids, and tricyclic antidepressants. In female patients, specific causes like organ prolapse, pelvic mass, and gravid uterus should be considered.

The pathophysiology of acute urinary retention can involve factors like increased resistance to flow, detrusor muscle dysfunction, bladder overdistension, and drugs that affect bladder tone. The primary management intervention for acute urinary retention is the insertion of a urinary catheter. If a catheter cannot be passed through the urethra, a suprapubic catheter can be inserted. Post-catheterization residual volume should be measured, and renal function should be assessed through U&Es and urine culture. Further evaluation and follow-up with a urologist are typically arranged, and additional tests like ultrasound may be performed if necessary. It is important to note that PSA testing is often deferred for at least two weeks after catheter insertion and female patients with retention should also be referred to urology for investigation.

Epididymo-orchitis refers to the inflammation of the epididymis and/or testicle. It typically presents with sudden pain, swelling, and inflammation in the affected area. This condition can also occur chronically, which means that the pain and inflammation last for more than six months.

The causes of epididymo-orchitis vary depending on the age of the patient. In men under 35 years old, the infection is usually sexually transmitted and caused by Chlamydia trachomatis or Neisseria gonorrhoeae. In men over 35 years old, the infection is usually non-sexually transmitted and occurs as a result of enteric organisms that cause urinary tract infections, with Escherichia coli being the most common. However, there can be some overlap between these groups, so it is important to obtain a thorough sexual history in all age groups.

Mumps should also be considered as a potential cause of epididymo-orchitis in the 15 to 30 age group, as mumps orchitis occurs in around 40% of post-pubertal boys with mumps.

While most cases of epididymo-orchitis are infective, non-infectious causes can also occur. These include genito-urinary surgery, vasectomy, urinary catheterization, Behcet’s disease, sarcoidosis, and drug-induced cases such as those caused by amiodarone.

Patients with epididymo-orchitis typically present with unilateral scrotal pain and swelling that develops relatively quickly. The affected testis will be tender to touch, and there is usually a palpable swelling of the epididymis that starts at the lower pole of the testis and spreads towards the upper pole. The testis itself may also be involved, and there may be redness and/or swelling of the scrotum on the affected side. Patients may experience fever and urethral discharge as well.

The most important differential diagnosis to consider is testicular torsion, which requires immediate medical attention within 6 hours of onset to save the testicle. Testicular torsion is more likely in men under the age of 20, especially if the pain is very severe and sudden. It typically presents around four hours after onset. In this case, the patient’s age, longer history of symptoms, and the presence of fever are more indicative of epididymo-orchitis.

For the treatment of young people under 16 years with lower urinary tract infection (UTI), it is important to obtain a urine sample before starting antibiotics. This sample can be tested using a dipstick or sent for culture and susceptibility testing. In cases where children under 5 present with fever along with lower UTI, it is recommended to follow the guidance outlined in the NICE guideline on fever in under 5s.

Immediate antibiotic prescription should be offered to children and young people under 16 years with lower UTI. When making this prescription, it is important to consider previous urine culture and susceptibility results, as well as any history of antibiotic use that may have led to resistant bacteria. If a urine sample has been sent for culture and sensitivity testing, the choice of antibiotic should be reviewed once the microbiological results are available. If the bacteria are found to be resistant and symptoms are not improving, a narrow-spectrum antibiotic should be used whenever possible.

For non-pregnant women aged 16 years and under, the following antibiotics can be considered:
– Children under 3 months: It is recommended to refer to a pediatric specialist and treat with an intravenous antibiotic in line with the NICE guideline on fever in under 5s.
– First-choice in children over 3 months: Nitrofurantoin (if eGFR >45 ml/minute) or Trimethoprim (if low risk of resistance*).
– Second-choice in children over 3 months (when there is no improvement in lower UTI symptoms on first-choice for at least 48 hours, or when first-choice is not suitable): Nitrofurantoin (if eGFR >45 ml/minute and not used as first-choice), Amoxicillin (only if culture results are available and susceptible), or Cefalexin.

Please refer to the BNF for children for dosing information. It is important to consider the risk of resistance when choosing antibiotics. A lower risk of resistance may be more likely if the antibiotic has not been used in the past 3 months, if previous urine culture suggests susceptibility (but was not used), and in younger people in areas where local epidemiology data suggest low resistance. On the other hand, a higher risk of resistance may be more likely with recent antibiotic use and in older people in residential facilities.