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UROLOGY > 8: LUTS > Flashcards

8: LUTS Flashcards

1
Q

what are the 3 categories of LUTS

A
  • storage symtpoms: frequency, nocturia, urgency, urge incontinence
  • voiding symptoms: hesitancy, poor flow, incomplete emptying, terminal dribble
  • post micturition symptoms: post-mic dribble
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2
Q

give 4 causes of LUTS

A
  • 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
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3
Q

what symptom should be considered in an older comorbid patient presenting with LUTS

A

nocturnal polyuria
- defined as > 1/3 of urine output at night

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4
Q

what causes nocturnal polyuria

A

loss of circadian urine output rhythm with age
- chronic deep venous insufficiency
- congestive cardiac failure
- COPD
- sleep apnoea
- diabetes
- CKD

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5
Q

what is the management of nocturnal polyuria

A
  • 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
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6
Q

how are LUTS investigated in a primary and secondary care setting

A
  • history
  • abdo, genital exam, DRE
  • urine dip
  • frequency-volume chart
  • PSA in men

secondary care:
- flow rate and post-mic residual volume
- urodynamics

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7
Q

how is flow rate interpreted

A

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

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8
Q

what does low/absent detrusor pressure suggest

A

detrusor failure
- can be idiopathic
- diabetes or other neuro issues
- follow-on from chronic retention

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9
Q

how is invasive urodynamic testing carried out

A
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10
Q

what are the 2 phases of urodynamic studies

A

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

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11
Q

what is the conservative treatment of BOO/BPH

A

lifestyle advice e.g. fluid intake, caffeine, etc

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12
Q

what is the medical treatment of BOO/BPH

A
  • alpha blockers e.g. tamsulosin, alfuzosin
  • 5-a reductase inhibitors e.g. finasteride
  • ## anticholinergics if OAB symptoms
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13
Q

what is the surgical treatment of BOO/BPH

A
  • TURP/various forms of laser prostate surgery
  • open retropubi (Millin’s)
  • prostatectomy
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14
Q

how do alpha blockers work in BPH and what are their side effects

A
  • 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
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15
Q

how do 5-alpha reductase inhibitors work in BPH and what are their side effects

A
  • 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
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16
Q

what are indications for surgery in patients presenting w LUTS

A

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

17
Q

what is TURP syndrome

A
  • 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
18
Q

what is OAB syndrome

A

defined as urgency +/- incontinence, often accompanied by frequency and nocturia
- occurs in both men and women
- in men often accompanies obstruction

19
Q

compare urge and stress incontinence

A

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

20
Q

what is the conservative treatment of OAB

A
  • weight loss, stop smoking, avoid caffeine
  • drink when thirsty
  • pelvic floor exercises
  • bladder training
21
Q

what is the medical treatment of OAB

A
  • anti-cholinergics e.g. oxybutynin, tolterodine, solifenacin
  • topical vaginal oestrogens in peri/-post menopausal women
  • bet 3 agonist e.g. Mirabegron
22
Q

what is the surgical treatment of OAB

A
  • 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
23
Q

what is the conservative treatment of stress incontinence

A
  • weight loss
  • supervised pelvic floor exercises
24
Q

why is duloxetine not routinely used to treat stress incontinence

A

side effects of arrhythmias and poor efficacy

25
Q

what is the surgical treatment of stress incontinence

A
  • TVT and TOT tape
  • autologous fascial sling
  • colposuspension
  • artificial urinary sphincter
  • urinary diversion (stoma)
26
Q

what are causes of stress incontinence in men (2)

A
  1. surgical injury to external sphincter or its nerve supply e.g. radical prostatectomy or TURP
  2. neuro problem affecting the sphincter
27
Q

what is the treatment of stress incontinence in men where pelvic floor exercises have failed

A

artificial urinary sphincter or male sling

28
Q

how does an artifical sphincter work

A
  1. cuff that surrounds and compresses urethra to prevent urine leakage
  2. cuff connected to pump in scrotum which the patient uses
  3. fluid filled resevoir/balloon placed in abdomen

! deactivate before catheterisation !

29
Q

what are causes of neurogenic OAB

A
  1. spina bifida
    • also causes stress incontinence
    • highest risk of developing hydronephrosis/renal failure
  2. 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
30
Q

what are other diffuse neuro conditions that can lead to urological symptoms

A
  • diabetes: loss of sensation, overdistension, detrusor failure
  • MS: neurogenic OAB, DSD leading to poor emptying
  • Parkinson’s
31
Q

what are the complications of TURP

A

TURP syndrome
Urethral stricture
Retrograde ejaculation
Perforation of prostate

32
Q

what phenomenon commonly occurs after catheterisation for chronic urinary retention

A

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

33
Q

what is the treatment of urge incontinence

A
  • anticholinergics
  • Mirabegnon B3 agonist
  • Botox injections

UROLOGY (8 decks)

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