| U |

In adults usually infected (fungal or bacterial) dermatitis, often with offensive discharge.

Precautions: consider umbilical fistula, carcinoma, umbilical calculus.

Management:

• Swab for micro and culture.

• Toilet—remove all debris and clean.

• Keep dry and clean—daily dressings.

• Consider Kenacomb ointment.

Apply a caustic pencil gently daily for about 5 d.

A testis that is not in the scrotum may be ectopic, absent, retractile or truly undescended.

The problem of non-descent

• Testicular dysplasia

• Susceptible to direct violence (if in inguinal region)

• Risk of malignant change (seminoma) is 5–10 times greater than normal

Optimal time for assessment

Between 3 and 6 mths (before development of cremasteric reflex and thus confusion with a retractile testis)

Review 2½–3 yrs—?acquired maldescent

Refer

• All undescended testes by 6 mths

• Acquired maldescent

• Concerned parents

• Doubtful position of testis

Optimal time for surgery

The optimal time for orchidopexy is 6–12 mths. Production of spermatozoa is adversely affected in undescended testes from 2 yrs onwards. Exploration for the uncommon impalpable testis is worthwhile.

Hormone injections

Injections of chorionic gonadotrophic hormones are generally not recommended. They are ineffective except for borderline retractile testes.

Leads to increased cardiovascular disease, death rate and psychiatric illness.

Objective is to prevent resignation, hopelessness and deterioration of health. Encourage positive outlook with readiness to re-enter labour force.

Vulnerable groups

• School leavers, esp. non-achievers (beware of impulsive overdoses)

• History of psychosomatic or physical disability

• Children of the unemployed

• Previous problematic marriages

• Men with many dependants

• Those >50 yrs with good job records

Role of GP

• Diagnostic awareness

• Foreshadow problems

• Caring, supportive counselling (very powerful)

• Liaison with social services

The important STIs that cause urethritis which may be asymptomatic (esp.♀s) are gonorrhoea and Chlamydia trachomatis.

Collection of specimens

Check with your laboratory. The conventional method is as follows.

• The NAAT (PCR) Chlamydia urine test (95% specific) is the preferred test (in both sexes), traditionally on the first catch urine specimen (don't urinate for 4 hrs) then first 10 mL passed in an ordinary MCU jar. However, now the specimen can be collected at any time—there is no minimum time since the last urination.

• New approaches are to collect a random sample by passing urine through a UriSWAB or self-collection from a tampon in females.

These tests are also used to diagnose gonorrhoea. However, PCR is less reliable in women for gonorrhoea than an endocervical specimen.

Taking swabs

• Standard swab for Gonococcus (into the urethral meatus): place into Stuart's transport medium

• Take an endocervical swab in females.

• For men who have sex with men the tests are first-pass urine, swabs of urethra, anus and throat.

Treatment of symptomatic patients should be based on results of Gram stain, culture and PCR/LCR for Chlamydial diagnosis.

Screening guidelines for higher risk

• All sexually active females <25 yrs

• All sexually active teenagers esp.♀ and ATSIP

• Those with a pattern of inconsistent or no condom usage

• Men who have sex with men

Chlamydia non-specific urethritis

• Azithromycin 1 g (o) as single dose (preferred) or

• Doxycycline 100 mg (o) 12 hrly for 7 d.

A second course may be required if the symptoms persist or recur (about 1 in 5 cases).

• Treat (same way) sexual partners (even if asymptomatic)

• Avoid sexual intercourse until resolution

Gonococcal infection

• Ceftriaxone 500 mg IM (dissolved in 2 mL 1% lignocaine) single dose plus either (if Chlamydia not ruled out on PCR)

• Azithromycin 1 g (o) single dose or doxycycline 100 mg (o) bd for 7 d If pharyngeal or anorectal infection: ceftriaxone 500 mg IM as single dose.

In remote Australia (low penicillin-resistant N.gonorrhoea):

• Amoxycillin 3 g + probenecid 1 g + azithromycin 1 g (ο)—all single dose

Consider the NSAID tiaprofenic acid as a cause of non-infective cystitis.

Treatment

• Treat all patients with symptomatic urinary infection.

• Treat these asymptomatic patients with bacterial UTI: neonates, preschool children, pregnant women, all those with known or presumed urinary tract abnormality and/or renal impairment, men <60 yrs.

Optimal treatment includes:

• high fluid intake

• complete bladder emptying, esp. at bedtime or after intercourse (women)

• urinary alkalinisation for severe dysuria (e.g. sodium citrotartrate 4 g orally 6 hrly)

Acute uncomplicated cystitis

Antimicrobial regimen

Multiple dose therapy preferred.

• Trimethoprim 600 mg orally or

• Gentamicin 120 mg IM or

• Nitrofurantoin 200 mg orally

• Use for 5 d in women (trimethoprim—3 d); for 10 d in women with known UT abnormality; for 14 d in men with acute cystitis

  • 

  • amoxycillin/potassium clavulanate 500/125 mg (o) 12 hrly or

  • nitrofurantoin 50 mg (o) 6 hrly or

  • norfloxacin 400 mg (o) 12 hrly (if resistance to above agents proven)

Follow-up: MSU 7 d later. Avoid using important quinolones—norfloxacin or ciprofloxacin—as first-line agents

All adult men with a UTI should be investigated to exclude an underlying abnormality, e.g. prostatitis, obstruction.

Acute cystitis in children >12 mths

Treatment should be continued for 5 d:

• trimethoprim 4 mg/kg (up to 150 mg) bd (suspension is 50 mg/5 mL) or

• cephalexin 12.5 mg/kg (up to 500 mg) bd or

• amoxycillin clavulanate 12.5/3.1 mg/kg (up to 500/125 mg) (o) bd

Norfloxacin is contraindicated in children.

Check MSU in 3 wks.

Urinary infections in pregnancy

Acute cystitis is treated for 10 d with any of the following antimicrobials: cephalexin, amoxycillin/potassium clavulanate or nitrofurantoin (if a beta-lactam antibiotic is contraindicated). The dosages are the same as for other groups. Asymptomatic bacteruria should be treated with a week-long course.

Urinary infections in the elderly

Treat uncomplicated symptomatic infections as for adults but not asymptomatic bacteruria.

Acute pyelonephritis

Mild cases: oral therapy (as for cystitis) but double dose except trimethoprim (same dose)

Severe:

• admit to hospital

• take urine for MCU and blood for culture

• amoxycillin 2 g IV 6 hrly plus

• gentamicin 4–6 mg/kg IV daily for 2–5 d then use oral therapy ASAP (total 14 d treatment)

Investigate all for an underlying LUT abnormality.

Treatment of recurrent or chronic UTI

A 10–14 d course of:

• amoxycillin/potassium clavulanate (500/125 mg) (o) 12 hrly or

• trimethoprim 300 mg (o) once daily or

• norfloxacin 400 mg (o) 12 hrly (if proven resistance to above agents)

Prophylaxis for recurrent UTI

In some female patients a single dose of a suitable agent after intercourse is adequate but, in more severe cases, courses may be taken for 6 months or on occasions longer:

• nitrofurantoin (macrocrystals) 50–100 mg (o) nocte or

• trimethoprim 150 mg (o) nocte or

• cephalexin 250 mg (o) nocte

Children use the same antibiotics according to age.

Note: Cranberry products (juice or tablets) may reduce incidence of symptomatic UTI in women but the evidence is not strong.

Indications for investigation of UTI

• All infants and children

• All males

• All women with:

  • acute pyelonephritis

  • recurrent infections >2 per yr

  • confirmed sterile pyuria

  • other features of kidney disease (e.g. hypertension)

Investigations for recurrent UTI

Basic investigations include:

• MSU–microscopy and culture (post–treatment)

• renal function tests: plasma urea and creatinine, GFR

• intravenous urogram (IVU), and/or US

Special considerations:

• in children: micturating cystogram

• in adult males: consider prostatic infection studies if IVU normal

• in severe pyelonephritis: ultrasound or IVU (urgent) to exclude obstruction

• in pregnant women: US to exclude obstruction

See Hives (papular urticaria)

Can be classified as:

• papular (hives) (e.g. insect bites): papules tend to persist

• giant-cell

  • widespread weals: tend to ‘come and go’

  • superficial—dermis = urticaria

  • deep—subcutaneous = angioedema

Check causes

• Food: nuts, esp. peanuts, chocolate, cheese, fish, eggs, etc.

• Drugs (e.g. aspirin, antibiotics)

• Infections (e.g. viruses—most common in children; bacteria; parasites; yeasts)

• Plants: nettles, Grevillea, Rhus

• Physical: exercise and heat, cold

Unknown aetiology in most cases (up to 80%).

Treatment

• Avoid any identifiable causes

• Antihistamines, e.g. cyproheptadine 16–32 mg (o) daily, non-sedating (e.g. fexofenadine 60 mg (o) bd)

• Lukewarm baths with Pinetarsol or similar soothing bath oil

• Topical 0.5% hydrocortisone—apply every 4 h for itching or soothing preparation (e.g. crotamiton 10% or phenol 1% in oily calamine)

If severe: prednisolone 50 mg once daily for 10 d.