Urology Archives - Page 3 of 3 - Healthed

Urology

Urology

Dr Linda Calabresi

Clinical Articles

Enuresis Management in General Practice

Australian GPs are confident and competent at managing kids with bedwetting issues, new research confirms.But they are less sure what to do with children with daytime wetting or when childhood enuresis persists into adulthood, according to the study findings recently published in the Australian Journal of General Practice.As you may remember, back in late 2016, health professionals on the Healthed database were invited to participate in a survey designed by leading paediatric urologist, Dr Patrina Caldwell to investigate their knowledge and experience with managing urinary incontinence in childhood.Almost 1500 Australian health professionals responded, mostly GPs. Researchers found that 88% of survey participants reported being slightly or very knowledgeable about managing childhood urinary incontinence. Their confidence seems well-founded at least for nocturnal enuresis.Having been given multiple answer options about first-line management, 93% of participants correctly selected urotherapy and enuresis alarm training as the ideal first-line management for childhood enuresis.This is despite less than half (48%) being able to correctly identify the commonest cause of the condition as being abnormal physiology of sleep and bladder function. Over a third of people incorrectly thought childhood enuresis was simply a delay in developing toileting skills.However, it is a different kettle of fish when it comes to managing daytime urinary incontinence which only 81% of participants felt at least somewhat confident managing. Of concern was the finding that 18% of health professionals would treat this condition with inappropriate and potentially harmful treatments. More specifically, a small percentage of participants chose tricyclic antidepressants which used to be a popular treatment option but is now no longer recommended as first-line therapy for daytime urinary incontinence due to its potential side-effects.The situation was even worse for adult patients who had problems with enuresis that had persisted since childhood. Only 61% of participants felt they were even slightly knowledgeable managing these patients, although most chose the most appropriate first-line therapy of urotherapy and desmopressin.According to the study authors, the knowledge of the health professionals with regard to the various categories of urinary incontinence was largely reflective of the prevalence of each of the different conditions in their clinical experience. Most GPs were currently managing at least a few cases of nocturnal enuresis but the other two conditions were much rarer.

Reference

Caldwell PHY. Manocha R, Hamilton S, Scott KM, Barnes EH. Australian community health practitioners’ knowledge and experience with managing urinary incontinence that begins in childhood. Aust J Gen Pract. 2019 Jan; 48(1-2); 60-5. Available from: https://www1.racgp.org.au/ajgp/2019/january–february/managing-urinary-incontinence-that-begins-in-child

Expert/s: Dr Linda Calabresi

Urology

Dr Daman Langguth

Clinical Articles

Investigation of Paraproteinaemia

Paraproteins are abnormal monoclonal immunoglobulins produced in plasma cell disorders (eg multiple myeloma), lymphoproliferative disorders (eg CLL, Waldenstrom’s macroglobulinaemia) and in some infections (hepatitis C).The introduction of the assay, serum free light chains (FLC) has meant the initial investigation of paraproteinaemia has become much simpler.Previously, serum tests had great difficulty in detecting immunoglobulin light chains for two reasons:1. Light chains are rapidly cleared by the kidneys, up until a certain point where they ‘spilled’ over into the blood. 2. Assays had poor sensitivity in detecting ‘free’ light chains ie light chains not bound to heavy chains as in normal immunoglobulin.The FLC assay (a propriety product) when combined with serum protein electrophoresis (EPP) and immunofixation allows detection of the vast majority (>99%) of paraproteins, virtually eliminating the need for urine collection and analysis, thus giving a greater degree of patient satisfaction.With nearly all very sensitive assays, there are some costs to specificity.In renal failure and in polyclonal gammopathy (such as in chronic inflammation, liver disease or infection), the FLC assay may suggest the presence of a monoclonal light chain when non is present, in up to 10% in some series. Tis also occurs in chronic renal failure with EPP and immunofixation testing. This must be kept in mind when investigating patients for paraproteins.The FLC assay only detects free (unbound) immunoglobulin light chains, so traditional serum EPP plus immunofixation must also be done on initial investigation. It has been shown that the vast majority of ‘non-secretory’ myelomas actually produce free light chains, detectable by this new assay.The serum FLC assay can be used to guide chemotherapy in myeloma, and has already been incorporated into some international response criteria for myeloma.SummaryThe FLC assay, when combined with serum EPP and immunofixation, allows the detection and evaluation of paraproteins.
General Practice Pathology is a new regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs.The authors provide this editorial, free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.

Expert/s: Dr Daman Langguth

Urology

Dr Linda Calabresi

Clinical Articles

Antibiotics Still Best For Suspected UTI

At a time when there is increasing pressure on GPs not to prescribe antibiotics, a new primary care study endorsing their role in the early treatment of uncomplicated UTI makes a welcome change.The trial, recently published in the BMJ showed that not only did early antibiotic treatment for a lower UTI significantly shorten the duration of symptoms, it also reduced the risk of the patient developing pyelonephritis.However, the researchers stopped short of recommending all women with lower UTI symptoms commence antibiotics at first presentation. In deference to the rising rates of antibiotic resistance against UTI-causing bacteria, and the fact that little harm came to the women who were originally in the NSAID group but were eventually put on antibiotics, they effectively suggest a ‘just in case’ script.“[A] strategy of selectively deferring rather than completely withholding antibiotic treatment may be preferable for uncomplicated lower UTI,” they said. The only caveat they suggested to this strategy, was for women who had lower UTI symptoms and a CRP greater than 10mg/L who appeared, in post hoc analysis to have a greater likelihood of developing pyelonephritis and might therefore benefit from immediate antibiotics. But this would need further research they suggested.The Swiss study, a randomised, double blind trial involved more than 250 women who presented to their GP with symptoms of an uncomplicated lower UTI, and were found to have either leucocytes or nitrite or both on a urine dipstick test. The women were randomised to receive either norfloxacin or the NSAID, diclofenac. The choice of norfloxacin as the antibiotic, which does seem a little like using a hammer to crack a nut, was based on pre-determined high susceptibility rates in this Swiss population and diclofenac was the NSAID chosen because it had the same dosing regimen as the norfloxacin.Overall, symptoms were gone after a median of two days in the antibiotic group but lasted twice as long in the NSAID group, with the majority of NSAID women eventually needing antibiotics. Also of note was that 5% of women in the NSAID group developed pyelonephritis compared with none in the antibiotic group.So even though research suggests we can safely withhold antibiotics in a number of self-limiting bacterial diseases such as acute otitis media, sinusitis and traveller’s diarrhoea – we should perhaps reconsider that strategy for treating UTIs, the study authors suggest.BMJ 2017; 359: j4784.http://dx.doi.org/10.1136/bmj.j4784

Expert/s: Dr Linda Calabresi