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Rules of Thumb
Rule of thumb in Urology

Author's details

  • Dr.Khashau Eleburuike
  • MBBS (Ilorin) MSc. Global Health Karolinska Institute.
  • Resident doctor in family medicine in Northen Sweden.

Reviewer's details

  • Professor Sulyman Alege Kuranga
  • MBBS, FWACS, Certificate in Record & Information (Harvard University, USA) Higher Diploma in Education (Israel) Consultant Urological Surgeon & Professor of Surgery.
  • University of Ilorin/University of Ilorin Teaching Hospital. Ilorin Kwara state Nigeria.

Rule of thumb in Urology

Background

Urology in Sub-Saharan Africa involves addressing a range of issues, from infectious diseases to non-communicable conditions, within a context of often limited resources and healthcare infrastructure. Practical rules of thumb and guidelines can help optimize care despite these challenges.

The following principles would aid management of urological patients in sub-Saharan Africa

  1. Thorough Clinical Evaluation: Start with a detailed patient history and physical examination to identify common urological issues such as urinary tract infections, benign prostatic hyperplasia, and urolithiasis. 
  2. Basic Diagnostic Tools: Utilize readily available diagnostic tools such as urinalysis, ultrasound, and basic blood tests. These can provide valuable information in the absence of more advanced imaging techniques.
  3. Early Detection and Management of Infections: Given the high prevalence of infections, promptly diagnose and treat urinary tract infections (UTIs), sexually transmitted infections (STIs), and schistosomiasis to prevent complications.
  4. Education and Prevention: Educate patients on hygiene, safe sexual practices, and the importance of hydration to prevent common urological problems. Public health campaigns can play a crucial role in reducing the incidence of preventable conditions.
  5. Task-Shifting and Training: Train general practitioners, nurses, and community health workers in basic urological care and procedures to extend the reach of urological services in rural and underserved areas.
  6. Resource Optimization: Make the best use of available resources. This includes using ultrasound for the diagnosis of renal and bladder conditions and relying on clinical judgment when advanced diagnostics are unavailable.

 

  1. Management of Chronic Conditions: For chronic conditions such as benign prostatic hyperplasia (BPH) and chronic kidney disease, focus on symptom management and improving the quality of life, often using medical management when surgical options are limited.
  2. Surgical Prioritization: When surgical intervention is necessary, prioritize life-threatening and quality-of-life-improving procedures. Basic surgical skills and procedures, such as catheterization and suprapubic cystostomy, should be well-practiced.
  3. Multidisciplinary Approach: Collaborate with other healthcare providers, including nephrologists, gynaecologists, and general surgeons, to manage complex cases effectively.
  4. Follow-Up Care: Ensure consistent follow-up to monitor treatment outcomes and manage any complications. Use community health workers for home visits and follow-up reminders when clinic visits are challenging for patients.
  5. Cultural Sensitivity: Respect and understand cultural beliefs and practices related to urological health. This can enhance patient trust and compliance with treatment plans.
  6. Adaptation to Local Contexts: Adapt global best practices to local settings, considering the available resources, infrastructure, and healthcare system limitations.

By following these principles, urologists and healthcare providers can deliver effective, culturally sensitive, and resource-appropriate urological care in Sub-Saharan Africa, improving patient outcomes and overall urological health in the region.

Rules of thumb
1. Management of Urinary Tract Infections (UTIs)
UTIs are common in sub-Saharan Africa and can lead to significant morbidity if not effectively managed. Congenital urinary tract abnormalities such as congenital double ureter is a cause of recurrent UTIs
Rules of Thumb
Prompt Diagnosis and Treatment:
Initiate empirical antibiotic treatment based on local resistance patterns while awaiting culture results. Ensure treatment is tailored based on the culture and sensitivity results when available. Hydration and Hygiene: Encourage patients to increase fluid intake to flush out bacteria and practice good personal hygiene to prevent recurrent infections.
Screen High-Risk Groups:
Screen pregnant women, diabetics, and individuals with kidney disease or congenital anomalies in the urinary tract for UTIs, as these groups are at higher risk of complications.
Guidelines
WHO Guidelines for UTI Management: Recommend empirical antibiotic treatment based on local epidemiological data and adjusting therapy according to culture results. Emphasize prevention strategies such as adequate hydration and hygiene. CDC UTI Guidelines: Provide protocols for the diagnosis and treatment of UTIs, including recommendations for antibiotic use and follow-up care.
2. Management of Acute Kidney Injury (AKI)
AKI is often caused by hypovolaemia, from low blood, excessive blood loss, medication side effects, and metabolic causes. Other causes of AKI are infections, dehydration, or toxins and can have high mortality rates in sub-Saharan Africa.
Rules of Thumb
Identify and Treat the Underlying Cause:
Address the primary cause of AKI, such as dehydration or infection. Ensure proper hydration and treat any underlying infections or toxic exposures. Give blood in the case of hypovolaemia.
Monitor Electrolytes and Fluid Balance:
Regularly monitor electrolyte levels and fluid status to guide treatment and prevent complications such as hyperkalaemia.
Referral for Dialysis:
In cases of severe AKI where conservative management is insufficient, refer patients for dialysis if available. In many areas, conservative management focuses on preventing progression.
Guidelines
KDIGO Clinical Practice Guidelines for AKI: Recommend early identification and management of AKI through fluid resuscitation, treatment of underlying causes, and monitoring of renal function. Dialysis should be considered when indicated. WHO Guidelines on AKI: Emphasize the importance of early diagnosis, management of complications, and referral to specialized care when necessary.
3. Management of Prostate Disorders
Benign prostatic hyperplasia (BPH) and prostate cancer are significant concerns in sub-Saharan Africa.
Rules of Thumb
Always perform a digital rectal examination (DRE) for a patient with suspected BPH or prostate cancer. Feel for the median fissure, presence of rough surfaces. The normal size prostate is the size of walnut that increases with age. The normal consistence of prostate feels like the tip of the nose.
Symptom Management:
For BPH, start with medical management using alpha-blockers or 5-alpha-reductase inhibitors. Surgical intervention, such as open prostatectomy is the gold standard in sub-Saharan Africa. Where available, transurethral resection of the prostate (TURP) or Holmium laser (HOLEP) where available, may be necessary for severe symptoms.
Screening for Prostate Cancer:
Implement screening programs for high-risk groups, such as men over 40 or those with a family history of prostate cancer. Prostate specific antigen (PSA) testing. High PSA requires prostate biopsy for confirmation and staging. However, having a normal PSA does not rule out prostate cancer. It is important to always do a DRE.
Referral for Advanced Cases:
For suspected prostate cancer or complicated BPH, refer patients to specialized centers for further evaluation and treatment.
Guidelines
American Urological Association (AUA) Guidelines for BPH: Recommend medical and surgical management options based on symptom severity. Encourage regular follow-up and reassessment of treatment efficacy. Prostate Cancer Screening Guidelines by the U.S. Preventive Services Task Force (USPSTF): Suggest personalized screening based on risk factors and patient preferences, highlighting the importance of informed decision-making.
4. Management of Urolithiasis (Kidney Stones)
Kidney stones are a common problem in sub-Saharan Africa, often related to dietary factors and dehydration.
Rules of Thumb
Hydration and Diet Modification:
Encourage patients to increase fluid intake to help prevent stone formation and manage existing stones. Advise dietary modifications to reduce the intake of stone-forming substances.
Pain Management:
Provide pain relief using analgesics and, if necessary, use medications to facilitate stone passage.
Referral for Surgical Intervention:
In cases of large stones, recurrent infections, or significant symptoms, refer patients for surgical intervention such as lithotripsy or ureteroscopy.
Guidelines
American Urological Association (AUA) Guidelines for Urolithiasis: Recommend dietary modifications, hydration, and pain management. Surgical options should be considered for large or symptomatic stones. European Association of Urology (EAU) Guidelines: Emphasize the importance of individualized treatment based on stone size, location, and patient symptoms. Include recommendations for medical management and surgical interventions.
5. Management of Erectile Dysfunction (ED)
Erectile dysfunction is a growing concern in sub-Saharan Africa, often associated with comorbid conditions like diabetes and hypertension.
Rules of Thumb
Identify Underlying Causes:
Assess for underlying conditions such as diabetes, hypertension, or psychological factors. Managing these conditions can improve ED symptoms.
Start with First-Line Treatments:
Use oral phosphodiesterase type 5 inhibitors (PDE5 inhibitors) like sildenafil if available. Address lifestyle factors, such as smoking cessation and weight management.
Psychosocial Support:
Provide counselling and support for psychological factors that may contribute to ED, as well as educate patients and their partners about the condition.
Guidelines
American Urological Association (AUA) Guidelines for ED:
Recommend a stepwise approach, starting with oral medications and addressing underlying health conditions. Include options for psychotherapy and alternative treatments if needed.
European Association of Urology (EAU) Guidelines on ED:
Provide comprehensive management strategies, emphasizing the importance of treating underlying health issues and offering various treatment options.
6. Management of Urinary Incontinence
Urinary incontinence is a common issue that can significantly impact quality of life and is often underreported in sub-Saharan Africa.
Rules of Thumb
Assess and Treat Underlying Causes:
Evaluate and manage underlying causes such as infections, diabetes, or neurological disorders. Implement behavioural therapies and pelvic floor exercises where feasible.
Use Simple Interventions:
For many cases, start with non-invasive treatments such as pelvic floor exercises (Kegel exercises) and lifestyle modifications like high fibre diet to treat or prevent constipation. Medication can be considered if available and appropriate.
Referral for Advanced Cases:
For persistent or severe incontinence, refer patients for further evaluation and treatment, which may include surgical options if available.
Guidelines
International Continence Society (ICS) Guidelines:
Emphasize a comprehensive assessment of urinary incontinence, including patient history, physical examination, and relevant diagnostic tests. Recommend conservative management approaches like behavioural modifications and pelvic floor exercises as first-line treatments. For more persistent cases, consider pharmacological treatments and surgical interventions based on individual patient needs.
International Continence Society (ICS) Guidelines:
Emphasize a comprehensive assessment of urinary incontinence, including patient history, physical examination, and relevant diagnostic tests. Recommend conservative management approaches like behavioural modifications and pelvic floor exercises as first-line treatments. For more persistent cases, consider pharmacological treatments and surgical interventions based on individual patient needs.
7. Management of Urological Cancers
Rules of Thumb
Early Detection and Referral:
Promote early evaluation of symptoms suggestive of urological cancers, such as haematuria, abnormal urinary patterns, or palpable masses. Early referral to specialized centers for diagnosis and management can significantly improve prognosis.
Supportive Care:
For patients with advanced urological cancers, provide comprehensive supportive care, including pain management, palliative care, and psychological support. In regions with limited access to advanced treatments, focus on symptom relief and improving quality of life.
Community Education:
Educate communities about risk factors for urological cancers, such as tobacco use, occupational exposures, and the importance of regular medical check-ups. Public awareness campaigns can help with early detection and prevention.
Guidelines
National Comprehensive Cancer Network (NCCN) Guidelines for Urological Cancers:
Detail a multidisciplinary approach to the management of urological cancers, including surgery, radiation therapy, and chemotherapy based on the specific type and stage of cancer. Emphasize the importance of early detection and personalized treatment plans.
European Association of Urology (EAU) Guidelines:
Provide specific recommendations for the diagnosis, treatment, and follow-up of urological cancers, including bladder, kidney, and testicular cancers. Highlight the need for early referral to specialist centers and a patient-centered approach to treatment.
Conclusion

In sub-Saharan Africa, urological conditions present unique challenges due to the interplay of infectious diseases, limited healthcare resources, and increasing prevalence of non-communicable diseases. Rules of thumb such as early intervention for urinary tract infections, addressing underlying causes of acute kidney injury, and managing common conditions like BPH and kidney stones with available resources are essential for improving patient outcomes.
Guidelines from global health organizations provide structured approaches to managing these conditions, helping to standardize care despite resource constraints. Emphasizing early diagnosis, conservative management, and supportive care while tailoring treatments to local contexts and available resources can significantly enhance the effectiveness of urological care in the region.
Efforts to strengthen healthcare infrastructure, increase access to essential treatments and diagnostics, and improve community education will be crucial in addressing the diverse urological health challenges faced in sub-Saharan Africa. By integrating practical approaches with evidence-based guidelines, healthcare providers can deliver effective care and improve outcomes for patients across the region.

Further readings

1. Madeline Moore, Charles Mabedi, Manraj Phull, Stephen R. Payne and Chandra Shekhar Biyani. The utility of urological clinical and simulation training for Sub-Saharan Africa. BJU Int 2022; 129: 563–571
doi:10.1111/bju.15731. BJU_15731 563..571 (baus.org.uk)
2. Payne SR, Chalwe M. Understanding the needs of low-income countries: how urologists can help. BJU Int. 2022 Jan;129(1):9-16. doi: 10.1111/bju.15628. Epub 2021 Nov 18. PMID: 34738315. Understanding the needs of low-income countries: how urologists can help – PubMed (nih.gov)
3. Campain N, Mabedi C, Savopoulos V, Payne SR, MacDonagh R. Understanding cultural and logistical contexts for urologists in low-income countries. BJU Int. 2022 Mar;129(3):273-279. doi: 10.1111/bju.15690. Epub 2022 Feb 2. PMID: 35044031. Understanding cultural and logistical contexts
for urologists in low-income countries – PubMed (nih.gov)
4. Coyle D, Nidaw E, Getachew H, Payne SR, Subramaniam R. Paediatric urology in Sub-Saharan Africa: challenges and opportunities. BJU Int. 2022 Sep;130(3):277-284. doi: 10.1111/bju.15852. Epub 2022 Aug 9. PMID: 35852384. Paediatric urology in Sub-Saharan Africa: challenges and opportunities – PubMed (nih.gov).

5. Ahmed Said et al. Landscape of Urology in Africa: Diversity and Disparity. March 2024. AUANZribi2403_revised-proof.pdf (pausaafrica.org)
6. BJU International © 2017 BJU International | doi:10.1111/bju.13897 BJU Int 2017; 119: 823 830Published by John Wiley & Sons Ltd. www.bjui.org wileyonlinelibrary.com NICE Guidance
7. Dason S, Dason JT, Kapoor A. Guidelines for the diagnosis and management of recurrent urinary ]tract infection in women. Can Urol Assoc J. 2011 Oct;5(5):316-22. doi: 10.5489/cuaj.11214. PMID: 22031610; PMCID: PMC3202002.
8. CDC Urinary Tract Infection Basics January 22, 2024. Urinary Tract Infection Basics | Urinary Tract Infection | CDC Accessed 13 th September 2024
9. Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012;120(4):c179-84. doi: 10.1159/000339789. Epub 2012 Aug 7. PMID: 22890468. KDIGO clinical practice guidelines for acute kidney injury – PubMed (nih.gov) Accessed 13 th September 2024
10. Mishra RC, Sodhi K, Prakash KC, Tyagi N, Chanchalani G, Annigeri RA, Govil D, Savio RD, Subbarayan B, Arora N, Chatterjee R, Chacko J, Khasne RW, Chakravarthi RM, George N, Ahmed A, Javeri Y, Chhallani AK, Khanikar RG, Margabandhu S, Lopa AJ, Chaudhry D, Samavedam S, Kar A, Dixit SB, Gopal P. ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy. Indian J Crit Care Med. 2022 Oct;26(Suppl 2):S13-S42. doi:
10.5005/jp-journals-10071-24109. PMID: 36896356; PMCID: PMC9989875. ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy – PMC (nih.gov) Accessed 13 th September 2024
11. Kaplan SA. AUA Guidelines and Their Impact on the Management of BPH: An Update. Rev Urol. 2004;6 Suppl 9(Suppl 9):S46-52. PMID: 16985925; PMCID: PMC1472912. Accessed 13 th September 2024.
12. World Health Organization. Accessed 13 th September 2024
13. U.S. Preventive Services. Prostate Cancer: Screening May 08,2018. Recommendation: Prostate Cancer: Screening | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org) Accessed 13 th September 2024
14. Akram M, Jahrreiss V, Skolarikos A, Geraghty R, Tzelves L, Emilliani E, Davis NF, Somani BK. Urological Guidelines for Kidney Stones: Overview and Comprehensive Update. J Clin Med. 2024 Feb 16;13(4):1114. doi: 10.3390/jcm13041114. PMID: 38398427; PMCID: PMC10889283.
Urological Guidelines for Kidney Stones: Overview and Comprehensive Update – PMC (nih.gov) Accessed 13 th September 2024
15. EAU. Prostate Cancer Prostate Cancer – INTRODUCTION – Uroweb Accessed 13 th September 2024

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