Department of family medicine

Department of Family Medicine
George Provincial Hospital
January 2009
Guidelines for patients needing Urology services in the Eden – Karoo districts
It is important to take note that there is no state Urologist in the Southern Cape – Karoo districts. Family Medicine serves as a buffer for this service, but patients needing surgical procedures beyond the 10 minor Urology procedures* should be referred to GSH or RXH directly. (Once George Hospital employs the services of an Urologist again, this position will change.) The Department of Family Medicine offers the following services to “Urology” patients*:  Telephonic consults with Dr Jenkins / Gibson / Family medicine registrar {044-802 4528) Exploration for Torsion of testis  Vasectomies  Orchidectomies  Circumcisions  Hydroselectomies  Prostate biopsies  El Ghoral shunt for priapism  Suprapubic catheters  Lister dilatation for urethra strictures (selected cases)  Reduction of paraphimosis  Cystoscopies  IVPs  Antero- & retrograde cysto-uretrogramo Ward admissions for conservative Mx of urinary stones, haematuria, UTIs, and septic Prospective orchidopexy for undescended testes, and babies with a “hydrocoele” (inguinal hernia) must receive an appointment at SOPD (Surgical Outpatients 044-802 4408). Women with stress incontinence or postmenopausal atrophy must get a GOPD appointment (Gyne Outpatients 044-802 4408). Patients needing TURPs, Optic Urethrotomies, Urethraplasty, or surgery or ESWL for urinary stones, must be referred directly to GSH Urology OPD (021-4045566). Patients referred to George Hospital Family Medicine clinics (Mon and Tuesday afternoons), must please come with the results of the basic investigations, as appropriate (PSA, Urine MCS and red cell morphology, Creatinine, PSA, Bladder & Kidney Sonar, IVP). This will avoid much to and fro travelling for the rural patients.
Please note the 2 options for theatre work:
Day theatre: Monday mornings weekly, and last Friday morning of the month. Bookings via Family Medicine OPD, who then books with the day theatre secretary (802-4338). Main theatre: Every 2nd Thursday afternoon. Bookings via Family Medicine OPD, who then books with the main theatre secretary (802-4343). This is for patients who need to be admitted to B1 the Wed prior to the list, for formal pre-op assessment and prep. 8 Urology Guidelines
Urinary Obstruction

Acute
Predisposing factors:
Overhydration, Delayed emptying time, DM, Drugs (Trepiline) Transurethral catheter {with Lignocaine jelly and FG 18 / 16 Selastic catheter}
Chronic
BPH: PSA, Cr.
PSA 4-10: Fractions +/- Prostate biopsy (District Hospital, or Day theatre) Alpha-blockers (Cardura XL 4-8 mg/d X 6 months) – S/E: postural hypotension Private script for Finasteride generic i/day po X 6 months. TURP if above fails (GSH Urology OPD appointment) If biopsy proves prostate cancer: If obstruction/bleeding/pain: BSCO {Bilateral subcapsular or total orchidectomy} Rarely {local intracapsular disease} – prostatectomy, radiation, (brachytherapy) – GSH Urology Oncology appointment UOPD – Optic Urethrotomy or Urethroplasty (GSH Urology OPD appointment) Urinary Incontinence

Stress History

Urge History
Anti-cholinergics {Oxybutinin (Ditropan) 5 mg tds / Tofranil / Amytryptaline}
Overflow
Intermittend self-catheterization / Indwelling catheter / Condom catheter / Nappies Morphine, Amlodipine 5 mg/d, Prednisone 30 mg/d, Voltaren 25-50 mg tds, Buscopan, Zinacef/Ciprobay IVP at earliest convenience (If Cr <200 and nil allergy to contrast) Ongoing pain / Obstruction / Sepsis (DM) / Rising Cr – Needs referral to GSH for Double-J stent / Perc. Nephrostomy / Lithotripsy (Urgent – Phone Urology registrar on call; Semi-urgent – Make appointment GSH Stone Clinic (E26) on a Friday: 021-4046114/22)) Ca/Urate stones – alkalinize urine (Citro-Soda) Urine dipstic to exclude orchitis (leucocytes) Explore in theatre < 6 hours (Fix opposite side)
Infection

Blood (Haematuria)
Urine MCS – Prove haematuria, exclude infection, differentiate renal vs urological causes (RBC morphology). FBC, Ur, Cr, PSA Bladder and Renal Sonar / IVP Cystoscopy if no obvious cause (especially > 50 years age)
5.
Impotence
Social habits: Smoking, Alcohol, Sleep, Stress Medications (B-blockers, antidepressants, etc) Emotional factors Illnesses: Peripheral vascular disease, DM, HPT, Neuro) Mx: Viagra / Cialis. Viagra: R100 / 100 mg tablet. Private script. Break tablet in half or quarters. Only C/I: Nitrates.
6.
Priapism
Erection > 24 hours. Glans does not participate. El Ghorap shunt. Followed up with BP cuff (pediatric) intermittend inflated X 48 hours. Digoxin load. Intrakavernose Ephedrine / adrenaline. Infertility
Smoking / alcohol DM (retrograde ejaculation) Spermiogram X 2 Lady: Ovulation / Anatomical block (tubes) – FSH, LH, Day21 progesterone, TSH, Sonar, Histerosalpingogram Refer GSH / TBH Infertility clinic (Costs!) Vasectomy Booking Guideline
 Phone the Day Theatre Secretary at 044-8024338.  Ask for a booking on the Monday morning or Friday morning Family Medicine theatre list.  Patient will receive a date for theatre, on a Monday or Friday morning.  On the date, draw a file at admissions.  Present at the Day Theatre at 07h30.  Give written permission (the standard sterilization/vasectomy form).  Go to theatre.  The procedure is done under local anaesthetic.  Patient can go home late morning or early afternoon, with pain killers.  If any questions, please ask Dr Jenkins or Gibson, or a Family medicine doctor.  There is no need to first be seen at the Urology or Family Medicine clinic.  The patient needs to understand that this is a permanent procedure.  After the vasectomy, the patient must take extra precautions (such as condoms or contraception for his partner) for 3 additional months.  Three months after the vasectomy the patient needs to present to the NHLS laboratory above the Emergency Unit and produce a fresh semen sample, for a spermiogram.  Only if the spermiogram confirms the absence of spermatozoa, is the patient considered
Dr L Jenkins
HOD: Fam Meds
George Hospital

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Source: http://www.georgehospital.co.za/docs/261/George%20Hosp%20Fam%20Meds%20Urology%20Guidelines%20Jan%202009.pdf