Importance of Checking for Prostate Cancer in Patients on Finasteride

Whilst other possibilities should not be disregarded, it is crucial to prioritize checking for prostate cancer in patients taking Finasteride. It is important to note that PSA values may be significantly reduced by up to 50% in patients taking 5-ARIs such as Finasteride, which can bring abnormal prostates into the normal range in terms of PSA values. Additionally, any increase in PSA levels should be a cause for concern, even if the absolute value is within the normal range, when a patient is taking Finasteride. It is essential to double the PSA readings of patients on Finasteride, which means that the corrected values for this patient are 6.2 and 6.0 ng/ml. Therefore, it is crucial to prioritize checking for prostate cancer in patients taking Finasteride to ensure timely diagnosis and treatment.

Patients taking warfarin have a comparable incidence of non-visible haematuria to the general population, and thus should be evaluated in the same manner. While most haematuria protocols recommend referring younger patients (under 40 years) to nephrology, this patient’s age warrants referral to urology for a cystoscopy.

Haematuria: Causes and Management

The management of haematuria can be challenging due to the lack of widely followed guidelines. Haematuria is now classified as visible or non-visible, with the latter being found in approximately 2.5% of the population. Transient or spurious non-visible haematuria can be caused by urinary tract infections, menstruation, vigorous exercise, or sexual intercourse. Persistent non-visible haematuria may be caused by cancer, stones, benign prostatic hyperplasia, prostatitis, urethritis, or renal conditions such as IgA nephropathy or thin basement membrane disease. Spurious causes of haematuria include certain foods and drugs.

Screening for haematuria is not recommended, and patients taking aspirin or warfarin should also be investigated. Urine dipstick is the preferred test for detecting haematuria, and persistent non-visible haematuria is defined as blood being present in 2 out of 3 samples tested 2-3 weeks apart. Renal function, albumin:creatinine or protein:creatinine ratio, and blood pressure should also be checked. NICE guidelines recommend urgent referral for patients aged 45 or older with unexplained visible haematuria or visible haematuria that persists or recurs after successful treatment of urinary tract infection. Patients aged 60 or older with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test should also be urgently referred. Patients under 40 years of age with normal renal function, no proteinuria, and who are normotensive may be managed in primary care.

Understanding eGFR Results and CKD Stages

When interpreting eGFR results, it is important to consider other markers of kidney damage such as albuminuria. An eGFR of 60-89 ml/min is considered mild and not indicative of CKD in the absence of albuminuria.

A sustained reduction in eGFR over three months is not indicative of acute kidney injury, which typically involves a sudden and drastic reduction in eGFR.

CKD stage 1 is diagnosed when eGFR is >90 ml/min and there is proteinuria (urine ACR >3 mg/mmol). This patient’s eGFR result of 62 ml/min and ACR of 2.5 mg/mmol doesn’t meet these criteria.

CKD stage 2 is diagnosed when eGFR is 60-89 ml/min and ACR is >3 mg/mmol. While the patient’s eGFR result fits this criteria, the sustained drop and normal ACR exclude this diagnosis.

CKD stage 3a is diagnosed when eGFR is 45-59 ml/min with or without other markers of kidney damage. This patient doesn’t meet this diagnostic marker.

In summary, understanding eGFR results and other markers of kidney damage is crucial in determining CKD stages.

Differentiating Causes of Haematuria: A Brief Overview

Haematuria, or the presence of blood in the urine, can be caused by a variety of conditions. One possible cause is glomerulonephritis, which is indicated by the presence of red-cell casts in the urine. In particular, post-streptococcal glomerulonephritis (PSGN) may be suspected if the patient has a recent history of tonsillitis. PSGN typically resolves on its own, but symptom control and infection removal may be necessary.

Another possible cause of haematuria is myoglobinuria, which is characterized by a positive urine dipstick but the absence of red-cell casts. Myoglobinuria is an early sign of rhabdomyolysis, which requires fluid resuscitation and further investigations into renal function and creatine kinase.

Porphyria, on the other hand, may cause dark or reddish urine due to excessive excretion of haem precursors. However, red-cell casts are not present and a urine dipstick would not be positive for blood.

Renal calculus, or kidney stones, is unlikely in a young patient and would typically be accompanied by severe pain. No casts would be present in this case.

Finally, a urinary tract infection (UTI) may cause haematuria, but a diagnosis requires significant bacteriuria, which is defined as greater than 100,000 colonies of bacteria per milliliter of urine. Counts between 10,000 and 100,000 are indeterminate, while counts below 10,000 are considered normal. Sensitivity testing may be necessary to determine the appropriate antibiotics for treatment.

In summary, the presence of red-cell casts in the urine suggests glomerulonephritis, while a positive urine dipstick without casts may indicate myoglobinuria. Other possible causes of haematuria include porphyria, renal calculus, and UTI, but these require further investigation and testing for diagnosis.

A patient with a urine ACR of 5 and an eGFR greater than 90 mL/min/1.73 m2 is classified as having G1A2 CKD. CKD is categorized based on the eGFR and urine ACR, with G1 representing stage 1 and an eGFR greater than 90 mL/min/1.73 m2, and A2 representing a urine ACR of 3-70 mg/mmol. Patients with G1A1 or G2A2 classification are not considered to have CKD in the absence of kidney damage markers.

Chronic kidney disease (CKD) is a condition where the kidneys are not functioning properly. To estimate renal function, serum creatinine levels are often used, but this may not be accurate due to differences in muscle. Therefore, formulas such as the Modification of Diet in Renal Disease (MDRD) equation are used to estimate the glomerular filtration rate (eGFR). The MDRD equation takes into account serum creatinine, age, gender, and ethnicity. However, factors such as pregnancy, muscle mass, and recent red meat consumption may affect the accuracy of the result.

CKD can be classified based on the eGFR. Stage 1 CKD is when the eGFR is greater than 90 ml/min, but there are signs of kidney damage on other tests. If all kidney tests are normal, there is no CKD. Stage 2 CKD is when the eGFR is between 60-90 ml/min with some sign of kidney damage. Stage 3a and 3b CKD are when the eGFR is between 45-59 ml/min and 30-44 ml/min, respectively, indicating a moderate reduction in kidney function. Stage 4 CKD is when the eGFR is between 15-29 ml/min, indicating a severe reduction in kidney function. Stage 5 CKD is when the eGFR is less than 15 ml/min, indicating established kidney failure, and dialysis or a kidney transplant may be necessary. It is important to note that normal U&Es and no proteinuria are required for a diagnosis of CKD.

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.

When treating a suspected urinary tract infection in pregnant women, it is important to follow NICE CKS guidance. This includes sending urine for culture and sensitivity before and after treatment, and starting treatment before awaiting culture results. Local antibiotic prescribing guidelines should be followed, but nitrofurantoin should be avoided at term due to the risk of neonatal haemolysis. Cefalexin is a safe alternative. The recommended course of antibiotics is seven days.

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 Urinary Symptoms: A Differential Diagnosis

Urinary symptoms can be caused by various conditions, and a differential diagnosis is necessary to determine the underlying cause. One possible cause is urethral stricture, which refers to the narrowing of the urethra due to scarring from inflammation, trauma, infection, tumors, or surgery. Patients may experience no symptoms, mild discomfort, or complete urinary retention. Another possible cause is benign prostatic hyperplasia, which can cause urinary frequency, poor stream, and terminal dribbling, but normal examination findings make prostatic disease unlikely. Bladder stones can also cause urinary symptoms such as suprapubic pain, dysuria, intermittency, frequency, hesitancy, nocturia, and urinary retention, as well as terminal hematuria and sudden cessation of voiding with associated pain. Chlamydia infection can cause urethritis with urethral discharge and dysuria, and a possible late complication is a stricture. Prostatic carcinoma can also cause similar symptoms, but the patient’s young age and normal examination of the prostate and PSA result make this diagnosis unlikely.

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.

It is common for men with a varicocele to experience pain or a sensation of heaviness or dragging in the scrotum. However, a varicocele on the right side alone is uncommon and requires referral to a urologist. Additionally, around 25% of men with abnormal semen parameters are found to have a varicocele, and this condition affects 40% of infertile men.

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.