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During the physical examination, a digital rectal examination and a focused neurological examination are
mandatory. Abdominal and external genital examinations are necessary to exclude distension of the
bladder, palpable urethral masses, and meatal stenosis.
Important diagnostic studies include urinalysis and a culture to rule out infection as well as urological
procedures. When available, urinary flow rate, post-void residual (PVR), and pressure-flow urodynamic
studies are appropriate tests to consider in men with moderate to severe symptoms. Urethrocystoscopy
may be considered in men with moderate to severe symptoms who have either chosen or require surgical
or other invasive therapy. This procedure is helpful in assisting the surgeon determine the best operative
approach.
9 IPPS: a scoring questionnaire, used to calculate the severity of voiding symptoms (see
http://www.usrf.org/questionnaires/AUA_SymptomScore.html)
ICAO Preliminary Unedited Version — November 2009 III-6-15
Radiographic studies of the upper tract are not helpful in men with lower urinary tract symptoms unless
they also have haematuria, renal insufficiency, a history of ureterolithiasis, urinary tract infection or
urinary surgery.
Management
Therapy is usually guided by patient symptomatology. Early conservative management is successful in
many patients; this may include lifestyle modifications such as decreasing fluid and salt intake and
avoiding caffeine and alcohol. If the patient has refractory urinary retention, the AHCPR10 and
International Consensus Guidelines recommend operative resolution of symptoms. Refractory retention is
defined as failing at least one attempt of urinary catheter removal. Other conditions that may mandate
surgery include recurrent urinary tract infection, recurrent gross haematuria, bladder stones, renal
insufficiency, or large bladder diverticula.
Transurethral resection of the prostate (TURP) is the most common definitive therapy for benign prostatic
hypertrophy. However, some patients are relieved by alpha-adrenergic antagonists (terazosin, prazosin,
doxazosin, and tamulosin). Five-alpha-reductase inhibitors such as finasteride are effective in relieving
men with larger palpable glands (>35 g) through its glandular “shrinking” effects, but it may take up to
six months for these to achieve full effect.
Alpha-antagonist medications are known to cause postural hypotension, syncope, dizziness and fatigue.
Although selective alpha-antagonists such as tamulosin have some incidence of postural hypotension and
mild dizziness, the incidence of these is far lower than in the alpha-agonists, especially in low doses.
Lastly, finasteride has only minimal side effects which include headache, impotence, and decreased
libido.
Aeromedical considerations
Temporary aeromedical disqualification may be necessary in the patient with symptomatic obstruction
secondary to benign prostatic hyperplasia (BPH). Judgment must be used in determining the aeromedical
significance of minimal or mild symptoms. As a general rule, if the licence holder is concerned enough to
mention the symptoms, then they are probably operationally significant.
Due to their side effects, alpha-antagonists are the least flight compatible medications of those
mentioned. Selective alpha-antagonists may be useful in the aviation environment after an uneventful
ground trial period. Even after ground trial, these medications should be considered unacceptable for
high g-force environments (aerobatics). Finasteride’s minimal side effects require a ground trial, but it
should be acceptable for most aviation duties.
TURP usually results in complete resolution of urinary symptoms, although up to 20 per cent may require
a second resection. The morbidity and mortality of this procedure is low but significant complications
may include retrograde ejaculation, impotence, and urinary incontinence. If the procedure resolves the
obstructive symptoms without morbidity, the individual will normally be qualified for aviation duties.
10 AHCPR: Agency for Health Care Policy and Research, an agency of the United States Public Health Service.
ICAO Preliminary Unedited Version — November 2009 III-6-16
UROLOGICAL MALIGNANCY
Overview
Urothelial malignancies, adenocarcinoma of the prostate, and renal cell carcinoma are the most commonly
seen urological malignancies. Testicular cancer is a rarer entity and is the main urological malignancy that
affects young populations.
Bladder cancer is the fourth most common cause of cancer in males and ninth in females. It has a 2.5 to 1
male to female ratio. With a median age of 65 at time of diagnosis, bladder cancer will be diagnosed in
over 53 000 individuals in North America annually. Transitional cell carcinoma is the most common
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Manual of Civil Aviation Medicine 2(3)
