Q: Renal colic
How urgently should I arrange an intravenous urogram (IVU) for renal colic if not admitted and is this worth doing once symptoms have resolved?
If the IVU does show hydro-nephrosis would this need outpatient or inpatient referral?
Generally speaking, some imaging is necessary on an urgent basis for patients with possible ureteric stones, since complete obstruction cannot be diagnosed clinically and mandates emergency therapy.
IVU is an acceptable option although spiral CT scanning has higher sensitivity for stone detection. Ultrasound alone is not adequate: small stones and early obstruction (without hydronephrosis) may be missed.
So by and large, emergency referral will be the norm for these patients, although if the patient's pain is controlled and there are no signs of sepsis this may be better arranged on a 'next clinic' basis with the urology team depending on local protocols.
Q: Investigating pyuria
A 55-year-old woman has urine showing pus cells, but no growth, on two occasions. What further tests are needed? What pathology is suspected?
A similar problem was experienced with a girl of 20.
In both a chlamydia test was negative.
The management of these two patients depends very much on the symptoms and the absence of haematuria.
Sterile pyuria in women who are asymptomatic and have no blood in the urine probably does not need investigation, unless it is at a stage where pus is actually visible.
If symptoms are present then, again, the presence or absence of haematuria and the presence or absence of risk factors for urethral tumours will influence the investigations carried out.
It would be more scrupulous to investigate a 55-year-old smoker than a 20-year-old non-smoker from the point of view of detecting bladder tumours.
Equally, a 20-year-old who had been holidaying in bilharzia areas might demand attention.
Urine microscopy is the first investigation, followed by imaging of the bladder and upper tracts as appropriate.
While CT urography will give the highest yield, kidney, ureters and bladder ultrasound with the an addition of a plain X-ray is probably used more in the UK.
In non-smokers without haematuria, the diagnosis yield at cystoscopy is limited but is practised by many specialists.
Cystoscopy will clearly exclude urothelial lesions with a high degree of accuracy.
However, overall, a few pus cells in the urine of either sex is nothing to be concerned about as long as there is no concomitant complications.
Mr Muir is consultant urologist at King's College Hospital, London
Sriprasad S, Kooiman G, Muir G, Sidhu P. Acute segmental testicular infarction: differentiation from tumour using high frequency colour Doppler ultrasound. Br J Radiol 2001; 74: 965-7.