1Topic 3.11 Urology AVMO 00172

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  1. Learning Objectives?
    • • Discuss the aeromedical implications of some renal and genitourinary disorders with respect to:
    • • The impact of the condition on the operating environment
    • • he impact of the aviation environment on the condition
    • • Immediate fitness to fly
    • • Outline the clinical information required including investigations and referrals to determine the aeromedical disposition
    • • Describe the aeromedical implications of possible treatments for renal/urinary disorders
    • • Discuss prognostic considerations that may impact on future fitness.
    • • Propose a likely MECR process and aeromedical disposition for genitourinary disorders
    • • Apply an evidence-based aeromedical decision making framework to the aeromedical management of disorders affecting the renal and genitourinary system
  2. Clinical Topics Covered?
    • • Asymptomatic microscopic haematuria and proteinuria
    • • Renal calculi
    • • Prostatic hypertrophy
    • • Glomerulonephritis (IgA nephropathy)
    • • Chronic Renal Failure
    • • Erectile dysfunction
    • • Irritable bladder
  3. Asymptomatic Haematuria and Proteinuria?
  4. Haematuria Overview?
    • • Microscopic haematuria defined as > 3 RBC/ hpf or > 10x106/L
    • • Dipstick testing: 91-100% sensitive and 65-90% specific for the detection of haemoglobin
    • • False positive
    • • The prevalence of asymptomatic microscopic haematuria varies from 0.19% to as high as 21%
  5. Causes?
    • • Trauma – “G”, exercise, sexual intercourse -24hrs
    • • Medication – e.g. warfarin/aspirin
    • • Benign enlargement of the prostate
    • • Urinary tract infection – lower or upper tract
    • • Kidney/ureteric/bladder stones
    • • Cancer of the urinary tract – urethra, prostate, bladder, ureter, kidney 10% of cases
    • • Polycystic kidney disease
    • • Intrinsic glomerular disease
  6. Aeromedical concerns?
    • • Haematuria may be due to a serious medical problem that could lead to sudden or subtle incapacitation inflight e.g. renal calculi
    • • Aviation environment may aggravate/precipitate underlying medical condition e.g. urinary retention in-flight may become a medical emergency due to lack of access to medical care
  7. Important Clinical Information?
  8. Factors that increase the likelihood of renal disease:?
    • • Proteinuria
    • • Impaired renal function
    • • Hypertension
    • • History suggestive of systemic disorder (new onset arthralgia, malaise, weight loss)
    • • Family history of renal disease
  9. Investigation and Referrals?
    • • Ensure correct result (repeat)
    • • Exclude benign causes
  10. Specialist Referral:?
    • • Red cell morphology will guide further investigation
    • • Glomerular red cells
    • • Renal function (eGFR) particularly if dipstick negative
    • • Ultrasound +/- plain abdo film (stones)
    • • Protein excretion – 24 hour urine collection
    • • Renal biopsy (>100,000 cells)
    • • Non-glomerular red cells
    • • CT IVP
    • • Cystoscopy
  11. Prognosis and Follow Up Requirements?
    • • Favourable prognosis if isolated microscopic haematuria
    • • Annual BP and UA for proteinuria
    • • U&Es and Cr and Specialist Referral if either above become an issue
  12. Aeromedical Disposition?
    • • Military:
    • • TMUFF during process for Investigation and Diagnosis - if any protein, frank blood or associated disease
    • • Unrestricted flying duties if isolated microscopic haematuria
    • • CASA:
    • • Treat as clinically indicated
  13. Proteinuria Overview?
    • • Dipstick: <2% positive for proteinuria have serious and treatable urinary tract disorders
    • • Sensitivity 88%, Specificity 96%
  14. Proteinuria?
    • • Ensure correct result
    • • repeat when adequately hydrated
    • • Must do 24 hour urinary protein excretion
    • • Specialist Referral:
    • • Management (normal <150mg/d):
    • • <1gm/day with normal renal function, BP and no haematuria -observe
    • • >1gm/day with or without normal renal function and/or haematuria - will need renal biopsy
  15. Renal Calculi?
    • Renal Calculi: Overview
    • • Lifetime prevalence: 7% of men and 3% of women
    • • Usually presents age 20-40
    • • Predisposing Factors – diet, hydration, infection, sedentary lifestyle, genetic – cysteinuria, renal tubular acidosis
    • • Renal colic - sharp, severe incapacitating pain, may be associated with nausea and/or vomiting
    • • Stone size has no correlation with severity of symptoms
    • • Urinalysis usually shows microscopic or gross haematuria
  16. Aeromedical Concerns?
    • • Sudden incapacitation
    • • The aviation environment can promote stone formation - dehydration, extremes of temperature, sedentary work, dietary factors
  17. Important Clinical Information?
    • History of risk factors:
    • • medication
    • • gout
    • • low fluid intake
    • • high animal protein intake
    • • high salt intake
    • • low calcium intake
    • • use of vitamin D supplements
    • • FHx of stones
    • Exam:
    • • Obs,
    • • GU focus
  18. Investigation and Referral Aims?
    • • Stone analysis
    • • UA (6/52 post stone clearance): pH, MCS;24hr urine-volume, calcium, oxalate, uric acid, citrate, magnesium, phosphorus, sodium, and
    • Cr excretion
    • • Bloods: U&Es and Cr, calcium, phosphate, uric acid; parathyroid hormone
    • • US or Low dose CT KUB
  19. Treatment Considerations?
    • • Clear all calculi in the collecting system and document with evidence
    • • Investigate and classify cause
    • • Prevention therapy
    • • Monitoring for compliance
  20. Treatment?
    • • Medication for distal ureteric calculi
    • • Surgery:
    • • Percutaneous nephrolithotomy (PCNL),
    • • Endoscopic shock wave lithotripsy (ESWL),
    • • Uroscopy and laser (URS)
    • • Dissolution of urate calculi with alkaline diuresis
    • • Prevention with fluids & medications
  21. Treatment?
    • • PCNL stone free rates 71-95%
    • • Retreatment 6%, ancillary procedures 0%
    • • ESWL stone free rates 41-54% to 75% at 3 months
    • • Retreatment 10% ancillary procedures 11%
    • • Residual fragments may be too small for other Rx
    • • Endoscopic Rx stone free after one treatment 100%
    • • ESWL Rx stone free after one treatment 35% (Zheng et al J Urol 2002:168)
    • • Urate calculi dissolved with alkaline diuresis
    • • Distal ureteric calculi up to 10mm may pass with help from tamsulosin (82% vs 35%, 12.3 days vs 24.5days)
  22. Prevention?
    • • 2.5L/day fluid intake then specific for cause
    • • Hyperoxaluria - limit diet, Ca supps
    • • Hyperuricosuria - low purine, allopurinol
    • • Hypocitraturia - pot citrate supps
    • • Hypercalciuria - thiazides (leak & type 1), low Ca, cellulose (type 2), orthophosphate (type 3)
    • • Check compliance
  23. Prognostic Considerations?
    • • Likelihood of stone passing within 1/12:
    • • 4 mm - 90%
    • • 5 mm - 50%
    • • 6 mm - 10%
    • • High recurrence rate:
    • • 10% within 1 year
    • • 35% within 5 years
    • • 50% within 10 years
    • 70% lifetime risk of recurrence
  24. Military Aeromedical Disposition?
    • • TMUFF until stone free or 4-6/52 post any procedure
    • • Likely MECR outcome - unrestricted or as/with co-pilot for 60 months
    • • Recurrent stones or retained stones – as/with co-pilot
  25. CASA Perspective?
    • • TMUFF until stone free or proven parenchymal stones
    • • Likely MECR outcome: return to unrestricted flying with regular review
    • • Recurrent stones or retained stones: as or with co-pilot
  26. Follow-up Requirements?
    • • Annual
    • • US KUB or
    • • Low dose CT KUB
  27. Benign Prostatic Hyperplasia (BPH)?
    • BPH Overview
    • • Prevalence is age-dependant
    • • Sx: frequency, nocturia, hesitancy, urgency, dribbling and weak urinary stream
    • • Increased risk of retention, UTI
  28. Aeromedical Concerns?
    • • Risk of retention: 5-8% per annum
    • • Lower urinary tract symptoms disruptive operationally
    • • Risk of chronic renal failure
    • • Unacceptable side effects of commonly used treatment medications
  29. Important Clinical Information?
    • • Hx – Symptoms
    • • Exam - PR
    • • Ix – UA, MCS, PSA, US – prostate, pre and post void residual
    • • Specialist Review
  30. Treatment Considerations?
    • • Alpha adrenergic antagonists (prazosin, Minipress) for bladder outlet obstruction – unacceptable in aviation due to side effects:
    • • Hypotension
    • • Palpitations
    • • Tachycardia
    • • Nasal congestion
    • • Miosis
    • • Tamsulosin (Flomaxtra)jQuery11010968544799749326_1488027114810?
    • • More selective alpha1 blocker
  31. Treatment Considerations?
    • • Acceptable Medications –
    • • saw palmetto,
    • • finasteride (5-alpha-reductase inhibitor)
    • • Surgery
    • • Follow up must be defined by specialist
  32. Military Aeromedical Disposition?
    • • TMUFF until adequately managed
    • • UMECR – return to unrestricted flying duties with regular specialist reports if adequately managed
  33. CASA Perspective?
    • • Treated BPH – unrestricted flying after successful surgery or on approved meds
    • • Prazosin – no ag flying or aeros
  34. Follow-up Requirements?
    • Ongoing annual specialist review to maintain aircrew category
  35. Glomerulonephritis (GN)?
    • Overview
    • • Common causes:
    • • Thin membrane nephropathy
    • • IgA nephropathy
    • • Others:
    • • Minimal change nephrotic syndrome
    • • Focal glomerulosclerosis
    • • Membranous nephropathy
    • • Crescentic glomerulonephritis (Incl. Anti-GBM, vasculitis etc)
    • • Membranoproliferative
    • • Focal proliferative
  36. IgA Nephropathy Overview?
    • • Most common cause of GN: 45% of cases
    • • Usually diagnosed by renal biopsy
  37. Aeromedical Considerations?
    • • Renal insufficiency/failure:
    • • fatigue
    • • susceptibility to infection
    • • oedema
    • • electrolyte disturbances
  38. Important Clinical Information?
    • • Spectrum of disease from benign to rapidly progressive renal disease
    • • Classify:
    • • 24hr urine protein >1g/day
    • • Hypertension
    • • Increased serum Cr
  39. Military Aeromedical Disposition?
    • • TMUFF while being investigated and diagnosed
    • • Initial: Class 4 – waiver if def benign
    • • Trained: Benign => Unrestricted flying duties with annual follow up:
    • • Specialist review inc BP
    • • U&Es and Cr
    • • 24hr Urine
  40. CASA Perspective?
    • • Fitness for flying duties based clinically
    • • Follow up:
    • • Specialist report inc BP
    • • U&Es and Cr
    • • 24hr Urine
  41. Chronic Renal Failure?
    • Overview
    • • Defined by biochemical markers of impaired renal function
    • • GFR <60ml/min/1.73m2 body surface area
    • • Causes: Diabetes, Hypertension, Glomerulonephritis, Tubulointerstitial disease
  42. Aeromedical Concerns?
    • • Renal insufficiency/failure signs and Sx:
    • • fatigue
    • • susceptibility to infection
    • • oedema
    • • electrolyte disturbances
  43. Important Clinical Information?
    • • History of symptoms
    • • BP
    • • eGFR
    • • U&Es and Cr
    • • 24hr Urine
  44. Investigations and Referrals?
    • Organise Specialist review and report on diagnosis, staging, prognosis and follow up requirements
  45. Military Aeromedical Disposition?
    • • TMUFF for investigations and MECR
    • • Initial: Class 4
    • • Recruits: CAMECR likely MEC4A4
  46. CASA Perspective?
    • • Fitness for flying duties clinically based
    • • Follow up:
    • • Specialist report inc m BP
    • • U&Es and Cr
    • • 24hr Urine
  47. Erectile Dysfunction (ED)?
    • Overview
    • • Inability to develop or maintain an erection
    • • Causes:
    • • Psychological
    • • CVD
    • • Diabetes
    • • Medications, alcohol
    • • Neurogenic Disorders
    • • Hormonal disorders
  48. Aeromedical Concerns?
    • Side Effects of Medications:
    • • PDE5 inhibitors
    • • Headache, migraine
    • • Hypotension
    • • blue /green vision disturbance
    • • Prostaglandins
    • • Hypotension
  49. Important Clinical Information?
    • • History – morning erections?
    • • Exclude underlying pathology
  50. Investigations and Referrals?
    • • Bloods –fasting BSL, Androgens, Prolactin
    • • Refer to specialist
    • • Ground trial and document side effects
  51. Aeromedical Disposition?
    • • Military and CASA
    • • Long acting meds e.g. tadalafil (Cialis) contraindicated
    • • TMUFF 72 hrs after use of sildenafil (Viagra), vardenafil (Levitra)
  52. Irritable Bladder?
    • Overview
    • • Detrusor instability = abdominal discomfort, urgency, urge incontinence, frequency, nocturia
    • • Females >> Males
  53. Aeromedical Concerns?
    • • Operational significance
    • • Subtle incapacitation
    • • Aviation environment can aggravate issue – “G”, cold, immobility
  54. Investigation and Referrals?
    • • MSU – UA, MCS
    • • Urology referral –urodynamic studies, cystoscopy
  55. Treatment Considerations?
    • • Anti-muscarinics for frequency, urgency unacceptable due to side effects:
    • • meiosis and blurred vision
    • • tachycardia, QT prolongation
    • • drowsiness
    • • hypotension
    • • headaches
    • • indigestion/ reflux
  56. Aeromedical Disposition?
    • • Must be adequately managed on approved treatment
    • • MECR: Case by case review and disposition
    • • Follow up requirements as specified by specialist
  57. Clinical Condition?
    TMUFF?
  58. Likelihood of clinical event:?
    • •Distraction
    • •Subtle incapacitation
    • •Aviation environment
    • Determined from:
    • •Investigations, urodynamics
    • •Referral Reports
    • Manage Consequences:
    • •Muticrew only
    • •As-or-with co-pilot

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david_hughm
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328902
Filename:
1Topic 3.11 Urology AVMO 00172
Updated:
2017-02-25 12:52:17
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Urology
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