This section is designed to address all questions from diagnosis to treatment. Please navigate through the lists below to move from symptoms to tests to treatment.

This procedure allows the urologist to inspect the bladder and urethra. It is performed with the aid of a telescope, that can be advanced along the water passage.

There are two ways to perform this procedure.

A rigid cystoscopy: In this situation a solid straight telescope is used. This telescope offers the best visualization of the bladder, and also allows other proedures to be performed in the bladder such as a biopsy, a retrograde pyelogram or the insertion of a ureteric stent. This approach commonly requires the use of a general anaesthetic.

A flexible cystoscopy: In this situation a flexible telescope
is used. This is a fibre optic instrument that can easily bend and pass along the curves of the urethra. This type of examination is commonly used for diagnosis and for the follow up of bladder tumours. It can also be used to remove ureteric stents and perform biopsies. A flexible cystoscopy can be performed using a local anaesthetic jelly, which means that it can be performed in an outpatient setting.
It can be performed in conjunction with twilight sedation which can make the procedure more pleasant.

A Cystoscopy may be ordered for the following reasons:

• Frequent urinary tract infections
• Blood in your urine (haematuria)
• Loss of bladder control (incontinence) or overactive
  bladder
• Unusual cells found in urine sample
• Need for a bladder catheter
• Painful urination, chronic pelvic pain, or interstitial cystitis
• Urinary blockage such as prostate enlargement,
  stricture, or narrowing of the urinary tract
• A stone in the urinary tract
• Unusual growth, polyp, tumor, or cancer
• Insertion or removal of a ureteric stent
• A retrograde pyelogram

A digital rectal examination is commonly performed during a visit to the urologist. It is probably the examination most feared by men. However it is not a painful procedure and takes only seconds to perform. This examination allows the urologist to examine the back passage and in men the prostate gland. The prostate lies immediately in front of the rectum (back passage).

The prostate gland can under go age related growth which is usually not of any great concern however it can also undergo cancerous change. This cancerous change can sometimes be detected from the examination. Not uncommonly cancer can be detected in this way despite a normal PSA reading.

The Digital Rectal Examination, is performed by inserting a gloved finger into the rectum. The gloved finger is
well lubricated. Afterwards the anal area is cleaned. If something suspicious is found such as firmness of the gland, then further tests might be required.

These tests might include an ultrasound or biopsy of the prostate gland. These tests might also be recommended if the PSA blood test is elevated.

Following a visit to the urologist, you may be asked for a blood or urine test, below is a list of the more commoner tests that might be requested.

blood tests

Full Blood Examination (FBE)— The haemoglobin level is checked and the different blood cells are looked at in detail under the microscope. Anaemia and inflammation can be detected from this blood test.

Urea Electrolytes and Creatinine (UE&C)— This test is a measure of kidney function. An elevated serum urea or creatinine level occurs with dehydration or if the kidney function is impaired. The electrolytes are the various
salts in the bloodstream, such as sodium, potassium, chloride and bicarbonate. The potassium level is of particular importance in people on diuretics or fluid tablets. Frequently the level falls in these patients and oral potassium supplements are required. The Calcium level in the blood stream may be assessed to determine the activity the health of the parathyroid gland and the bones. It is also useful information in treating patients with kidney stones.

Liver function tests (LFT’s)— The levels of several liver enzymes rise markedly when the liver is damaged by infections like hepatitis, or by toxins like alcohol and certain drugs. It is important to know the health of the liver in many situations as it can affect a patients ability to recover from a number of illnesses or injuries including surgery. ient where bile secretion from the liver is blocked, an elevated bilirubin level is seen. We also measure the protein and albumin levels; with chronic illnesses the albumin tends to gradually fall to quite low levels.

Cholesterol, triglyceride and other blood lipid levels— A high blood cholesterol level is an important risk factor for heart and arterial disease, including the small blood vessels that feed the penis. HDL-cholesterol seems to
be protective and so this lipid is preferable over LDL- cholesterol. LDL-cholesterol appears a major factor in the development of disease. Various ratios of HDL, LDL and total cholesterol are also used and may be more accurate predictors of heart and arterial disease. An elevated triglyceride level is also significant and so needs to be taken into account.

Other Blood Tests— Blood tests to check the levels of certain hormones might be prescribed to determine the cause of;

• Impotence
• Recurrent urinary stones
• Uro-gynaecological cases

A PSA test is another blood test. It stands for prostate specific antigen. PSA is a substance produced by the prostate gland and it plays a role in fertility. The vast majority is actually released into the ejaculate but tiny amounts escape into the blood stream and can be detected by a blood test.

An elevated PSA in most cases indicates an abnormality
in the prostate gland. The commonest abnormalities are inflammation in the prostate gland such as infection which can cause pain, Non-cancerous enlargement of the prostate gland which is associated with urinary symptoms, and lastly prostate cancer. Prostate cancer in its early stage
has no symptoms but obviously the most worrisome of the three possibilities. An elevated PSA might be the only clue that there is a problem.

As men age, the prostate gland grows and so the PSA count in the blood stream rises. This needs to be taken into account when assessing the results of the test. Certain prescription and herbal medications can also affect this level.

PSA is a useful tool for diagnosing and monitoring prostate diseases, but further tests are required to confirm which condition is present.

x-rays

Plain x-rays of the chest, abdomen and bones are often taken. Plain x-rays have the least amount of radiation exposure of all x-rays apart form ultrasound and MRI which have none.

A chest x-ray has the least of all the plain x-rays. Plain x-rays may be ordered for the following reasons:

• To assess if cancer has spread to these areas
• To assess kidney stones
• To plan operations
• To follow-up abnormal bone scans

intravenous pyelogram

An intravenous pyelogram is a diagnostic x-ray of the kidneys, ureters, and bladder. It involves injecting a contrast agent or a dye into a vein in the arm. This dye is then taken by the blood stream to the kidney where it will start to appear. A number of plain x-rays are then taken where the progress of the dye through the urinary system can be monitored and as such it will help outline an abnormality if it is present. An intravenous pyelogram may be ordered for the following reasons, including:

• to search for tumours in the kidney or bladder.
• to search for blockages of the urinary system.
• to search for kidney or bladder stones.
• to investigate blood in the urine.
• to detect injuries to the urinary tract.

ultrasound

An ultrasound scan is a common screening and follow-
up tool used in urology. It uses sound waves to build up a picture of the inside of the body. As x-rays are not used harmful radiation is not emitted to the patient. In most cases it is not as sensitive as a CAT scan or an MRI scan, but these tests are more expensive and CAT scans do emit significant radiation to the patient, so their use needs to be judicious. An ultrasound may be ordered for the following reasons:

• to search for tumours in the kidney or bladder to search for blockages of the urinary system to search for kidney or bladder stones
• to investigate blood in the urine
• to investigate difficulty urinating
• to search for dilatation of the kidney
• to assess the prostate gland
• to perform biopsies on the prostate gland

A special type of ultrasound called a transrectal ultrasound (TRUS) is performed when biopsies of the prostate gland are performed. A small probe is passed into the back passage and the prostate gland is scanned. Through this small probe a needle can be directed into the prostate gland and a number of very small samples of prostate tissue are taken. This procedure is commonly performed under twilight sedation and is generally well tolerated. The tissue is then sent to a pathologist who can tell by using a microscope whether cancer is present or not.

bone scans

A bone scan is performed in a number of situations. It essentially gives a pic ture of the health of your bones. It can tell if cancer has spread to the bones. It can tell if you have a fracture, and it can tell if the bones are thin. It can also detect and follow-up conditions that only affect the bones such as Paget’s disease.

It involves the injection of a small amount of radioactive material into a vein and following the tracer to the bones. Abnormal bone absorbs more of the radioactive substance than normal bone and shows up on the scan as highlighted areas (known as ‘hot spots’). If hot spots do show up further x-rays might be required.

The level of radioactivity that is used is equivalent to the dose that one might receive form a CAT scan, or a very long aircraft trip. This level is quite harmless but it is important to remember that most x-rays have an accumulative effect.

A bone scan might be ordered for the following reasons:

•  to evaluate a new diagnosis of cancer
• to check if cancer has spread to the bones
• to investigate non-cancerous bone disease
• to check if the bones are thin
• to check if Paget’s disease is present

ct scan (cat scan)

A CT or CAT scan is basically an x-ray tube that rotates in a circle around the patient and takes a series of pictures as it rotates. The multiple x-ray pictures are reconstructed by a computer in axial slice images at different levels. Each level can be examined separately.
The scan takes from 10-30 minutes. You may be given a drink or injection of a dye, which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it is important to let your doctor know beforehand.You will probably be able to go home as soon as the scan is over. A CT scan might be ordered for the following reasons

• to investigate a new diagnosis of cancer
• to check if cancer has spread to lymph nodes
• to investigate kidney stones
• to investigate injury to the urinary system
• to investigate blood in the urine

magnetic resonance imaging (mri or nmr scan)

Magnetic Resonance Imaging (MRI) is a noninvasive imaging technique. This test is similar to a CT scan but uses magnetism instead of X-rays to build up cross- sectional pictures of your body. It is used to view organs, soft-tissue, bone, and other internal body structures. In an abdominal MRI, the person’s body is exposed to radio waves while in a magnetic field. An individual is not exposed to harmful radiation during this test. Unfortunately an MRI scan does not detect kidney or bladder stones and cannot be used for this purpose. An MRI scan might be ordered for the following reasons:

• to investigate a new diagnosis of cancer
• to check if cancer has spread to surrounding tissues
• to investigate injury to the urinary system
• to investigate subtle soft tissue abnormalities
• to investigate a problem during pregnancy

nuclear medicine scan

A nuclear medicine scan or radio-nucleotide scan is a very similar test to a bone scan. The process is the same except that in this case the area of interest is the kidney and not the bones. Once again a radio-active substance is injected into a vein in the arm and travels to the kidney to be excreted. As it goes through the kidney it can be used to indicate if the kidney is blocked and to estimate its function. It can also give a breakdown of the function of each individual kidney. A nuclear medicine scan emits the same level of radiation as does a bone scan, and while usually harmless is not always insignificant. A nuclear medicine scan might be ordered for the following reasons

• to investigate blockage of the urinary system
• to estimate the function of a kidney

A urodynamic assessment is usually requested when a patient complains of urinary incontinence or voiding difficulty. It’s purpose is to help the treating doctor decide on the cause of the problem so that the treatment can be targeted at the cause. It is a sophisticated test that involves a number of phases. It is performed as an outpatient assessment in much the same way as x-rays are. In many cases it is carried out in an x-ray department. The test is performed by a specialist nurse and a urologist. It takes approximately 1 hr to complete. It is not painful and does not require an anaesthetic.

On arrival in the department, you will be asked to pass urine into a device called a flow-rate machine. Afterwards You will be asked to change into a hospital robe and be escorted in our practice to the radiology department where the procedure will take place. You will be positioned comfortably on an x-ray table and two small tubes inserted, one into the urethra (water pipe) and the other into the anus (back passage). After the tubes have been inserted, your bladder may be emptied and the tubes connected to the measuring apparatus.

During the test, your bladder will be filled slowly with water and dye at a measured rate. You will be asked to cough and strain at intervals and to tell us when you first feel the desire to pass urine. You will then be encouraged to hold on until your bladder feels quite full. At various times during the procedure an X-ray picture of your bladder will be taken. If one of your symptoms is leakage of urine, we will try to reproduce this so that we can see what the bladder is doing when the leakage occurs. Patients often feel this embarrassing. Please be reassured that it is an important part of the test and that we will do all we can do to be as supportive as possible during this process. The procedure itself should not be painful but some people may find it uncomfortable.

A special type of ultrasound called a transrectal ultrasound (TRUS) is performed when biopsies of the prostate gland are performed. A small probe is passed into the back passage and the prostate gland is scanned and measured. Through this small probe a needle can be directed into the prostate gland and a number of very small samples of prostate tissue are taken. The tissue is then sent to a pathologist who can tell by using a microscope whether cancer is present or not.

The most common reason for performing this test is because either a blood test called the PSA is abnormally high or the findings on examining the prostate through the back passage are abnormal.

The procedure is generally well tolerated and takes approximately 15 minutes to perform. It is performed as a day case. The commonest and most pleasant way to perform this procedure is with twilight sedation. It is important to recognize that after twilight sedation, the patient will need someone to drive them home and stay with them for the first 24hrs.