ACT Urinary

Question 1

Aetiology of urinary retention

Answer 1

Obstruction:

• Enlarged prostate – BPH or Ca
• Constipation
• Pregnancy

Reduced detrusor power:

• Post-operative, alcohol
• Pain (+ UTI)
• Drugs - Anticholinergics
• Neurological - Spinal pathology, MS, DM! (autonomic neuropathy)

Question 2

Investigation of urinary retention

Answer 2

Bedside: Dipstick + PR (tone, prostate, loaded rectum)
Bloods: FBC, U+E, PSA
Imaging: USS Bladder, Renal USS if AKI
Micro: MC+S

Question 3

Management of Urinary retention

Answer 3

Acute = URGENT CATHETERISATION

• Record residual volume drained – normal = 400 - 500ml
• Consider acute on chronic if > 1L
• Dip urine and send for MC+S
• Monitor fluid balance – post-obstructive diuresis
• Treat the cause eg. constipation
• Trial without catheter (TWOC) once causes addressed

For chronic retention:
- intermittent self-catheterisation (only if pain/anuric)
Medical: Tamsulosin – 0.4mg/day (alpha blocker)
Surgical: ? Transuretral resection of prostate (TURP)

Question 4

Describe Benign prostatic hyperplasia

Answer 4

Diffuse proliferation of stromal and glandular cells in the prostate.

Inner zone enlargement = BPH
Outer zone enlargement = carcinoma

LUTS – urgency, frequency, nocturia, hesitancy, overflow etc

Question 5

Investigation of suspected benign prostatic hyperplasia

Answer 5

Abdominal + external genitalia examination
Digital rectal examination - smooth central enlargement
Urine dipstick
U&Es if concern of kidney function
PSA test
- if positive - Transrectal biopsy

Question 6

Management of benign prostatic hyperplasia

Answer 6

Conservative: avoid caffeine, alcohol, void twice

Medical: alpha blockers (SEs drowsiness, depression, ejaculation fail)

Surgery:
TURP – 14% become impotent
Transurethral vaporisation of prostate - alternative
Beware TURP syndrome – absorption of washout
- Fluid overload, hyponatraemia, hypothermia, seizures

Transurethral incision of prostate (TUIP)
- if prostate less than 30g - less risk

Question 7

Aetiology of hyperkaleamia

Answer 7

AKI or CKD
Drugs - ACEi, potassium sparing diuretics 
Trauma - rhabdomyolysis, burns
Metabolic acidosis 
Addisons 
FALSE - Haemolysed sample

Question 8

Management of hyperkalaemia

Answer 8

Treat If K > 6.5mmol/L or > 6mmol/L with ECG changes

10ml Calcium Gluconate 10% slow IV
10U Actrapid in 50ml of 50% glucose over 30mins
Salbutamol 5mg nebulised
Calcium resonium 15mg TDS

R/V medications
If persistent - speak to renal - Dialysis?

Question 9

Aetiology and classification of Lower urinary tract infections and likely organisms

Answer 9

Female, Pregnancy
Sexual intercourse, use of spermicide
Elderly, post menopausal 
Diabetes Mellitus, Immunosupression
Stones, Structural abnormalities of renal tract 
Catheterisation

E.coli, proteus, klebsiella

Uncomplicated or Complicated:
Abnormal GU/renal tract, voiding obstruction, poor renal function, DM, immunocompromised, hospital acquired, catheter related, failure of Rx

Question 10

Assessment and Investigation of suspected LUTI

Answer 10

Abdominal exam
Beside: Urine dip
Nitrites - conversion of nitrates to nitrites, specific but only 30% sensitive, False –ve with polyuria or non-nitrate reducing organisms.
Leucocyte - 80% sensitive, but false +ve from vagina, low urine volume
Blood - 80% of UTIs, false +ve from menstrual blood/renal stones
Micro: MSU for MCS
Bloods: FBC, U+Es, CRP, Glucose

Question 11

Management of systemically well Lower Urinary Tract Infection

Answer 11

Paracetamol, or ibuprofen in appropriate
Drink enough to avoid dehydration
Wipe front to back
Void regularly, before bed and after sex

Medical: Treat empirically if nitrites OR leucocytes are positive (send MSU)
Trimethoprim 200mg BD PO 3 days, (7 if male, 10 if complicated)
Nitrofurantoin 50mg TDS PO 3 days (7 if male, 10 if complicated)

Question 12

When to refer to systemically well men with LUTI to secondary care

Answer 12

Urgent 2 week referral for:

• 45+yo with unexplained visible haematuria without UTI, or visible haematuria that persists or recurs after successful treatment of UTI
• 60+yo with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.

Urology - All men with 1st episode of pyelonephritis
LUTI not responding to treatment
Recurrent LUTI - 2 or more in 6 months
Risk factors or suspected underlying cause for LUTI

Nephrology - persistent microscopic haematuria with proteinuria or impaired renal function

Question 13

Indications for haemofiltration

Answer 13

Acidosis
Electrolyte imbalance
Intoxication
Overload
Uraemia

Question 14

Investigation of suspected benign prostatic hyperplasia

Answer 14

Digital rectal exam - smooth enlarged prostate
Urinalysis - exclude infection, check for haematuria
PSA after counselling

Urinary frequency-volume chart:
- distinguish frequency, polyuria, nocturia
International Prostate Symptom Score (IPSS):
- Assess the impact on the patient’s life.
- Classifies symptoms as mild, moderate or severe

Question 15

Management of voiding symptoms in men with BPH

Answer 15

Watchful waiting - Patient education
Alcohol and caffeine avoidance
Pelvic floor muscle training,

if ‘moderate’ or ‘severe’ symptoms:
- alpha-blocker eg. Tamsulosin
If the prostate is enlarged and the patient is ‘considered at high risk of progression’:
- 5-alpha reductase inhibitor eg. Finasteride
If enlarged prostate and ‘moderate’ or ‘severe’ symptoms:
- alpha-blocker + 5-alpha reductase inhibitor
If mixed symptoms of voiding and storage not responding to an alpha blocker then add anticholinergic

Surgery: transurethral resection of prostate (TURP)