1Topic 3.11 Urology AVMO 00172

• • 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

• • Asymptomatic microscopic haematuria and proteinuria
• • Renal calculi
• • Prostatic hypertrophy
• • Glomerulonephritis (IgA nephropathy)
• • Chronic Renal Failure
• • Erectile dysfunction
• • Irritable bladder

• • 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%

• • 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

• • 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

• • Proteinuria
• • Impaired renal function
• • Hypertension
• • History suggestive of systemic disorder (new onset arthralgia, malaise, weight loss)
• • Family history of renal disease

• • Ensure correct result (repeat)
• • Exclude benign causes

• • 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

• • 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

• • 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

• • Dipstick: <2% positive for proteinuria have serious and treatable urinary tract disorders
• • Sensitivity 88%, Specificity 96%

• • 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

• 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

• • Sudden incapacitation
• • The aviation environment can promote stone formation - dehydration, extremes of temperature, sedentary work, dietary factors

• 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

• • 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

• • Clear all calculi in the collecting system and document with evidence
• • Investigate and classify cause
• • Prevention therapy
• • Monitoring for compliance

• • 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

• • 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)

• • 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

• • 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

• • 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

• • 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

• • Annual
• • US KUB or
• • Low dose CT KUB

• BPH Overview
• • Prevalence is age-dependant
• • Sx: frequency, nocturia, hesitancy, urgency, dribbling and weak urinary stream
• • Increased risk of retention, UTI

• • 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

• • Hx – Symptoms
• • Exam - PR
• • Ix – UA, MCS, PSA, US – prostate, pre and post void residual
• • Specialist Review

• • 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

• • Acceptable Medications –
• • saw palmetto,
• • finasteride (5-alpha-reductase inhibitor)
• • Surgery
• • Follow up must be defined by specialist

• • TMUFF until adequately managed
• • UMECR – return to unrestricted flying duties with regular specialist reports if adequately managed

• • Treated BPH – unrestricted flying after successful surgery or on approved meds
• • Prazosin – no ag flying or aeros

• Ongoing annual specialist review to maintain aircrew category

• 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

• • Most common cause of GN: 45% of cases
• • Usually diagnosed by renal biopsy

• • Renal insufficiency/failure:
• • fatigue
• • susceptibility to infection
• • oedema
• • electrolyte disturbances

• • Spectrum of disease from benign to rapidly progressive renal disease
• • Classify:
• • 24hr urine protein >1g/day
• • Hypertension
• • Increased serum Cr

• • 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

• • Fitness for flying duties based clinically
• • Follow up:
• • Specialist report inc BP
• • U&Es and Cr
• • 24hr Urine

• Overview
• • Defined by biochemical markers of impaired renal function
• • GFR <60ml/min/1.73m2 body surface area
• • Causes: Diabetes, Hypertension, Glomerulonephritis, Tubulointerstitial disease

• • Renal insufficiency/failure signs and Sx:
• • fatigue
• • susceptibility to infection
• • oedema
• • electrolyte disturbances

• • History of symptoms
• • BP
• • eGFR
• • U&Es and Cr
• • 24hr Urine

• Organise Specialist review and report on diagnosis, staging, prognosis and follow up requirements

• • TMUFF for investigations and MECR
• • Initial: Class 4
• • Recruits: CAMECR likely MEC4A4

• • Fitness for flying duties clinically based
• • Follow up:
• • Specialist report inc m BP
• • U&Es and Cr
• • 24hr Urine

• Overview
• • Inability to develop or maintain an erection
• • Causes:
• • Psychological
• • CVD
• • Diabetes
• • Medications, alcohol
• • Neurogenic Disorders
• • Hormonal disorders

• Side Effects of Medications:
• • PDE5 inhibitors
• • Headache, migraine
• • Hypotension
• • blue /green vision disturbance
• • Prostaglandins
• • Hypotension

• • History – morning erections?
• • Exclude underlying pathology

• • Bloods –fasting BSL, Androgens, Prolactin
• • Refer to specialist
• • Ground trial and document side effects

• • Military and CASA
• • Long acting meds e.g. tadalafil (Cialis) contraindicated
• • TMUFF 72 hrs after use of sildenafil (Viagra), vardenafil (Levitra)

• Overview
• • Detrusor instability = abdominal discomfort, urgency, urge incontinence, frequency, nocturia
• • Females >> Males

• • Operational significance
• • Subtle incapacitation
• • Aviation environment can aggravate issue – “G”, cold, immobility

• • MSU – UA, MCS
• • Urology referral –urodynamic studies, cystoscopy

• • Anti-muscarinics for frequency, urgency unacceptable due to side effects:
• • meiosis and blurred vision
• • tachycardia, QT prolongation
• • drowsiness
• • hypotension
• • headaches
• • indigestion/ reflux

• • Must be adequately managed on approved treatment
• • MECR: Case by case review and disposition
• • Follow up requirements as specified by specialist

TMUFF?

• •Distraction
• •Subtle incapacitation
• •Aviation environment
• Determined from:
• •Investigations, urodynamics
• •Referral Reports
• Manage Consequences:
• •Muticrew only
• •As-or-with co-pilot