Genitourinary (former).pdf

ESAM Academy Basic Course 2024 Genitourinary System Thibaut F. Gaillard, MD 27/04/2024 The ESAM ACADEMY 1 General objectives Determine the relation between genitourinary abnomalies and aviation safety Determine the mi...

ESAM Academy Basic Course 2024 Genitourinary System Thibaut F. Gaillard, MD 27/04/2024 The ESAM ACADEMY 1 General objectives Determine the relation between genitourinary abnomalies and aviation safety Determine the minimal set of examinations to be conducted during aeromedical evaluations Determine the proper actions to be taken in case of pathological findings Review the major genitourinary conditions 27/04/2024 The ESAM ACADEMY 2 Relation to aviation 27/04/2024 The ESAM ACADEMY 3 Relation to aviation 1368 (1%) urological in-flight medical emergencies from a total of 138612 in-flight medical emergencies Incidence of 0.5 per million passengers Hancock J, Sui W, Alves P, Nerwich N, Hsi RS. Urological In-Flight Medical Events on Commercial Airlines. J Urol. 2020 May;203(5):991-995. 27/04/2024 The ESAM ACADEMY 4 Relation to aviation Hancock J, Sui W, Alves P, Nerwich N, Hsi RS. Urological In-Flight Medical Events on Commercial Airlines. J Urol. 2020 May;203(5):991-995. 27/04/2024 The ESAM ACADEMY 5 Relation to aviation 67 (72%) Hohmann E, Pieterse R. Temporary incapacitation rates and permanent loss of medical license in commercial airline pilots. Aerosp Med Hum Perform. 2023; 94(3):113–121. 27/04/2024 The ESAM ACADEMY 6 Aeromedical examination 27/04/2024 The ESAM ACADEMY 7 Aeromedical examination Urinalysis shall form part of each aero-medical examination. Which test strip to choose? 27/04/2024 The ESAM ACADEMY 8 Dipstick urinalysis Specific Gravity Urobilinogen Leucocytes Bilirubin Ketones Glucose Nitrites Protein Blood pH 10-Test SQ SQ SQ SQ Q SQ Q SQ Q SQ 9-Test SQ SQ SQ Q SQ Q SQ Q SQ 7-Test SQ SQ SQ Q SQ Q SQ 6-Test SQ SQ Q SQ SQ SQ 5-Test SQ SQ Q SQ SQ 5-Test D SQ SQ SQ Q SQ 4-Test N SQ SQ Q SQ 3-Test SQ SQ SQ 3-Test E SQ SQ SQ 2-Test SQ Q Source: https://diagnostics.roche.com 27/04/2024 The ESAM ACADEMY 9 Dipstick urinalysis – Specific gravity Reflects the ability to concentrate or dilute the urine Must be > 1022 after a 12-hour period without food or water intake Decreased (1035): Dehydration (fever, vomiting, diarrhea), SIADH, adrenal insufficiency, pre-renal renal failure, hyponatraemia with oedema, liver failure, CCF, nephrotic syndrome https://litfl.com/dipstick-urinalysis/ 27/04/2024 The ESAM ACADEMY 10 Dipstick urinalysis - pH Control of pH is important in the management of several diseases Usually not a diagnostic tool https://litfl.com/dipstick-urinalysis/ 27/04/2024 The ESAM ACADEMY 11 Dipstick urinalysis - Protein Normal daily protein excretion should not exceed 150 mg/24 hours or 10 mg/100 mL Most sensitive to albumin, do not detect Bence-Jones globulin (multiple myeloma, lymphoma, macroglobulinaemia) True elevation may reflect a renal disease, cardiac disease, functional response to stressors or be the results of drugs intake https://litfl.com/dipstick-urinalysis/ 27/04/2024 The ESAM ACADEMY 12 Dipstick urinalysis – Leuco & Nitrites A positive leucocyte esterase test correlates well with pyuria A positive nitrite test is a surrogate marker of bacteriuria with Gram-negative microorganisms https://litfl.com/dipstick-urinalysis/ 27/04/2024 The ESAM ACADEMY 13 Dipstick urinalysis – Blood Positive reaction indicates haematuria from «all» possible causes! https://litfl.com/dipstick-urinalysis/ 27/04/2024 The ESAM ACADEMY 14 Dipstick urinalysis – Ketones End products of incomplete fat metabolism Associated with low carbohydrate (high fat/protein) diets, starvation, diabetes, alcoholism, eclampsia and hyperthyroidism https://litfl.com/dipstick-urinalysis/ 27/04/2024 The ESAM ACADEMY 15 Dipstick urinalysis – Glucose Glucose is not normally present in the urine Glycosuria occurs in patients with elevated serum glucose levels in the presence of a reduced renal threshold and reduced glucose reabsorption in renal tubular disease with certain drugs (such as cephalosporins, penicillins, nitrofurantoin, methyldopa, tetracycline, lithium, carbamazepine, phenothiazines, steroids and thiazides) https://litfl.com/dipstick-urinalysis/ 27/04/2024 The ESAM ACADEMY 16 Dipstick urinalysis – Bilirubin & UBG Bilirubin is not present in the urine of healthy individuals Urobilinogen is normally present in the urine in low concentrations Normal Biliary Hepatic Haemolytic obstruction disease disease Bilirubin Negative Positive Positive Negative Urobilinogen Positive Decreased Increased Increased https://litfl.com/dipstick-urinalysis/ 27/04/2024 The ESAM ACADEMY 17 Dipstick urinalysis Which test strip to choose?! Specific Gravity Urobilinogen Leucocytes Bilirubin Ketones Glucose Nitrites Protein Blood pH 10-Test SQ SQ SQ SQ Q SQ Q SQ Q SQ 9-Test SQ SQ SQ Q SQ Q SQ Q SQ 7-Test SQ SQ SQ Q SQ Q SQ 6-Test SQ SQ Q SQ SQ SQ 5-Test SQ SQ Q SQ SQ 5-Test D SQ SQ SQ Q SQ 4-Test N SQ SQ Q SQ 3-Test SQ SQ SQ 3-Test E SQ SQ SQ 2-Test SQ Q Source: https://diagnostics.roche.com 27/04/2024 The ESAM ACADEMY 18 Dipstick urinalysis ICAO is specifically mentioning glucose, protein & blood No further EASA indication about the minimal set of tests NAA may choose an extended minimal set Screenshot EMPIC Switzerland 27/04/2024 The ESAM ACADEMY 19 Abnormalities in routine dipstick urinalysis Applicants shall be assessed as unfit where their urine contains abnormal elements considered to be of pathological significance […] What does “pathological significance” mean? MED.B.035 27/04/2024 The ESAM ACADEMY 20 What does “pathological significance” mean? “It is understood that a degree of interpretation and assessment must be exercised by the medical examiner, often in consultation with specialists and the medical assessor of the Licensing Authority ” ICAO ICAO Manual of Aviation Medicine, 2012 27/04/2024 The ESAM ACADEMY 21 A pragmatic approach 27/04/2024 The ESAM ACADEMY 22 Major genitourinary conditions and their related aeromedical considerations 27/04/2024 The ESAM ACADEMY 23 Usual urinary system disorders during aeromedical evaluations Urinary calculi Haematuria Urological infection Benign prostatic hyperplasia and hypertrophy 27/04/2024 The ESAM ACADEMY 24 Urinary calculi Regulation (EU) 2019/27 MED.B.035 ED Decision 2019/002/R AMC7 MED.C.025 27/04/2024 The ESAM ACADEMY 25 Urinary calculi ED Decision 2019/002/R AMC2 MED.B.035 27/04/2024 The ESAM ACADEMY 26 Applicants with an asymptomatic calculus or a history of renal colic require investigation Specialized urological evaluation Main consideration: Risk of migration Risk of recurrence Operational environment 27/04/2024 The ESAM ACADEMY 27 Haematuria Haematuria is among the most commonly encountered diagnoses in urology Recommended investigation of asymptomatic microscopic haematuria is inconsistent Urine dipstick alone is inadequate to establish a diagnosis of microscopic haematuria (North American consensus) Linder, B.J., Bass, E.J., Mostafid, H. and Boorjian, S.A. (2018), Guideline of guidelines: asymptomatic microscopic haematuria. BJU Int, 121: 176-183. 27/04/2024 The ESAM ACADEMY 28 Haematuria Haematuria by itself is unlikely to be aeromedically significant However, this sign must be fully evaluated “Any red cells found in the license holder’s urine should be the cause of a complete work-up” ICAO Manual of Aviation Medicine, 2012 27/04/2024 The ESAM ACADEMY 29 A pragmatic approach 27/04/2024 The ESAM ACADEMY 30 Urological infection Should be considered disqualifying for aviation duties during acute disease Defer your decision until the condition is over 27/04/2024 The ESAM ACADEMY 31 Benign prostatic hyperplasia and hypertrophy AME assessment & interpretation must be used in determining the aeromedical significance of minimal or mild symptoms If the license holder is concerned enough to mention the symptoms, then they are probably operationally significant Always consider the side effects of the usual alpha-antagonists prescribed 27/04/2024 The ESAM ACADEMY 32 Other disease and surgery Regulation (EU) 2019/27 MED.B.035 27/04/2024 The ESAM ACADEMY 33 Take home messages 27/04/2024 The ESAM ACADEMY 34 Take home messages Urological in-flight medical incapacitations are rare Urological manifestations during the aeromedical examination are (very) common Be pragmatic and use your clinical skills Communicate your thoughts & decision Aviation safety is your key role 27/04/2024 The ESAM ACADEMY 35 Thank you for your participation [email protected] 27/04/2024 The ESAM ACADEMY 36