8: LUTS Flashcards
what are the 3 categories of LUTS
- storage symtpoms: frequency, nocturia, urgency, urge incontinence
- voiding symptoms: hesitancy, poor flow, incomplete emptying, terminal dribble
- post micturition symptoms: post-mic dribble
give 4 causes of LUTS
- bladder flow obstruction: mainly in men due to BPH, urethral strictures
- overactive bladder: primary, secondary due to obstruction or other causes e.g. carcinome in situ, neurogenic, radiation, infection
- UTI: dysuria and positive dip/MSU
- bladder stones
what symptom should be considered in an older comorbid patient presenting with LUTS
nocturnal polyuria
- defined as > 1/3 of urine output at night
what causes nocturnal polyuria
loss of circadian urine output rhythm with age
- chronic deep venous insufficiency
- congestive cardiac failure
- COPD
- sleep apnoea
- diabetes
- CKD
what is the management of nocturnal polyuria
- advise pt to reduce night-time fluids
- low dose loop diuretic 4-6 hours before bed
- desmopressin as last resort as can cause serious electrolyte/fluid retention problems in the elderly
how are LUTS investigated in a primary and secondary care setting
- history
- abdo, genital exam, DRE
- urine dip
- frequency-volume chart
- PSA in men
secondary care:
- flow rate and post-mic residual volume
- urodynamics
how is flow rate interpreted
need voided volume of 150ml minimum
- Qmax >15mls/sec = 10-30% chance of obstruction
- Qmax 10-15mls/sec = 60% chance of obstruction
- Qmax <10mls/sec = 90% chance of obstruction
what does low/absent detrusor pressure suggest
detrusor failure
- can be idiopathic
- diabetes or other neuro issues
- follow-on from chronic retention
how is invasive urodynamic testing carried out
what are the 2 phases of urodynamic studies
filling phase
- should be slow, gentle rise in pressure (good compliance)
- phasic contractions associated w urgency = detrusor overactivity which is a feature of OAB but not always seen
- pt asked to cough for stress incontinence
voiding phase
- high pressure, low flow = obstruction
- low/absent pressure, low flow = detrusor failure
what is the conservative treatment of BOO/BPH
lifestyle advice e.g. fluid intake, caffeine, etc
what is the medical treatment of BOO/BPH
- alpha blockers e.g. tamsulosin, alfuzosin
- 5-a reductase inhibitors e.g. finasteride
- ## anticholinergics if OAB symptoms
what is the surgical treatment of BOO/BPH
- TURP/various forms of laser prostate surgery
- open retropubi (Millin’s)
- prostatectomy
how do alpha blockers work in BPH and what are their side effects
- relax prostatic/bladder neck smooth muscle
- tamsulosin is uro-selective
- doxazosin reserved for BP control if needed
- improve symptoms only
- side effects: retrograde ejaculation, postural hypotension
how do 5-alpha reductase inhibitors work in BPH and what are their side effects (2 main actions)
- reduce conversion of T - DHT
- reduce prostatic volume
- takes 6 months to see full effect
- only works w enlarged prostatee (>30g, PSA>1.4)
- can reduce progression of disease/reduce need for surgery
- side effects: ED, decreased libido, rash
what are indications for surgery in patients presenting w LUTS
failure of medical therapy
- LUTS not controlled by meds
- acute retention - failed TWOC on alpha-blockers
development of complications
- chronic retention (esp high pressure)
- bladder stones
- benign prostatic haematuria if persistent
what is TURP syndrome
- irigation for standard TURP is glycine not saline and this acts as an electrical insulator to prevent current dispersing
- absorption during a long resection can lead to dilutional hyponatraemia –> confusion, fits, visual symptoms, coma
- bipolar/laser TURP to avoid this problem
- triad of features: hyponatremia, fluid overload, glycine toxicity
what is OAB syndrome
defined as urgency +/- incontinence, often accompanied by frequency and nocturia
- occurs in both men and women
- in men often accompanies obstruction
compare urge and stress incontinence
stress
- provoked by laughing, coughing, sneezing
- leak a small amount
- no sensation of urge
urge
- preceded by sensation of urgency
- can also be provoked by coughing
- other stimuli e.g. running water, cold
- leak large amounts
what is the conservative treatment of OAB
- weight loss, stop smoking, avoid caffeine
- drink when thirsty
- pelvic floor exercises
- bladder training
what is the medical treatment of OAB
- anti-cholinergics e.g. oxybutynin, tolterodine, solifenacin
- topical vaginal oestrogens in peri/-post menopausal women
- bet 3 agonist e.g. Mirabegron
what is the surgical treatment of OAB
- botulinum toxin injections: need re treatment every 6-12 months + risk of retention so must be willing/able to self-catheterise
- sacral nerve stimulation
- ileocystoplasty
what is the conservative treatment of stress incontinence
- weight loss
- supervised pelvic floor exercises
why is duloxetine not routinely used to treat stress incontinence
side effects of arrhythmias and poor efficacy
what is the surgical treatment of stress incontinence
- TVT and TOT tape
- autologous fascial sling
- colposuspension
- artificial urinary sphincter
- urinary diversion (stoma)
what are causes of stress incontinence in men (2)
- surgical injury to external sphincter or its nerve supply e.g. radical prostatectomy or TURP
- neuro problem affecting the sphincter
what is the treatment of stress incontinence in men where pelvic floor exercises have failed
artificial urinary sphincter or male sling
how does an artifical sphincter work
- cuff that surrounds and compresses urethra to prevent urine leakage
- cuff connected to pump in scrotum which the patient uses
- fluid filled resevoir/balloon placed in abdomen
! deactivate before catheterisation !
what are causes of neurogenic OAB
- spina bifida
- also causes stress incontinence
- highest risk of developing hydronephrosis/renal failure
- spinal cord injury
- also causes areflexic bladder depending on level
- sphincter can be overactive (detrusor-sphincter dyssynergia) or underactive (neurogenic stress incontinence)
- variable risk of hydronephrosis dependent on gender (M>F) and nature of cord lesion
what are other diffuse neuro conditions that can lead to urological symptoms
- diabetes: loss of sensation, overdistension, detrusor failure
- MS: neurogenic OAB, DSD leading to poor emptying
- Parkinson’s
what are the complications of TURP
TURP syndrome
Urethral stricture
Retrograde ejaculation
Perforation of prostate
what phenomenon commonly occurs after catheterisation for chronic urinary retention
decompression haematuria
- due to rapid decrease in pressure in bladder
- does not require further treatment and will resolve
- monitor to ensure it does not become severe
what is the treatment of urge incontinence
- anticholinergics
- Mirabegnon B3 agonist
- Botox injections
