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formers, the risk ranges from 20-50% over the first ten years with an overall lifetime recurrence rate of
70%. Luckily, however, most smaller stones and even stones up to 8-10 mm diameter will pass
spontaneously in less than two weeks, despite the often incapacitating pain they produce.
Retained asymptomatic stones pose some risk for future renal colic. However, if the stones are located
such that they are unlikely to pass into the calyx, the risk for incapacitation during flight is low. If the
urinary studies do not reveal any underlying risk factors for recurrent stone formation, then medical
certification for aviation duties may be considered. However, environments that predispose to
dehydration may encourage renal stone formation without other underlying factors.
HAEMATURIA OF UROLOGICAL ORIGIN
Blood in the urine is a relatively common sign in the primary care or emergency department settings.
Asymptomatic microscopic haematuria has a reported prevalence of 1.2 to 5.2% in young adult males and
as high as 13% in community population-based studies. Haematuria may be the heralding sign for a
medical condition, which may not necessarily be an aeromedical disqualifier, but may necessitate an
aeromedical evaluation and disposition.
Disease process
The differential diagnosis of asymptomatic urological haematuria without proteinuria or casts includes
neoplasm, calculi, infection, and trauma (including exercise). Bleeding into the urinary tract from a source
between the urethra and the renal pelvis should result in no protein, cells or casts. Haematuria at the
beginning or end of the stream may indicate a urethral or prostatic source. Haematuria of any degree
should never be ignored and, in adults, should be regarded as a symptom of urological malignancy until
proven otherwise. Overall, it is uncommon for a patient with gross haematuria to have an unidentifiable
source as opposed to the frequently negative urological examination in patients with microscopic
haematuria.
Diagnosis
The evaluation of upper and lower urinary tracts is mandatory for all patients with haematuria.
Radiographic contrast studies such as the IVU or retrograde pyelogram will assist with urothelial
evaluations. Renal parenchyma can be studied with ultra-sonography, computed tomography, or magnetic
resonance imaging. The urethra and bladder will need cystourethroscopy.
Management
Focused care for the identified source of bleeding is necessary. Stone eradication for patients with
nephroureterolithiasis is necessary; definitive care for malignant or prostatic sources will have to be
directed by urologists.
Aeromedical considerations
ICAO Preliminary Unedited Version — November 2009 III-6-6
As mentioned previously, haematuria by itself in this setting is unlikely to be aeromedically significant.
However, this sign must be fully evaluated. Calculi can cause extreme pain, lead to urinary tract
infection, and obstruction. Urinary neoplasms are often slow growing but they must be diagnosed and
treated early to optimize survival and function. Glomerular disease must be evaluated and renal function
assessed to determine proper treatment and to address world-wide aviation duty (e.g. renal reserve, ability
to tolerate dehydration, etc.). Although most sources recommend evaluation for those greater than 3-5
RBC/hpf3, any red cells found in the licence holder’s urine should be the cause of a complete work-up.
INCONTINENCE
Urinary incontinence is the failure of voluntary control of the vesical and urethral sphincters with constant
or frequent involuntary urination. A careful history of the incontinent patient will often determine the
aetiology. Urinary incontinence can be subdivided into four categories: continuous, stress, urge, and
overflow incontinence.
Disease process
Continuous incontinence is defined as involuntary urination regardless of time or position. Ectopic ureter
and urinary fistulous disease are the predominant aetiologies, both of which warrant surgical remediation.
The sudden leakage of urine with activities that increase intra-abdominal pressures (i.e. coughing,
sneezing, exercise, etc.) refers to stress urinary incontinence. Although stress incontinence is commonly
associated with weakened pelvic support of the bladder neck and urethra in females, it may also be seen
in males, most often after prostatic surgical procedures.
Urination preceded by urgency to void is known as urge incontinence. Urge incontinence may be a
heralding symptom of malignant or infectious disease since these may cause urothelial irritation.
Neurogenic bladder, resultant from multiple aetiologies, can also induce urge incontinence.
Overflow incontinence results from elevated residual urine and subsequent inability to completely empty
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Manual of Civil Aviation Medicine 1(151)
