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Block 1- Kim > Altered Voiding and Urinary Obstruction > Flashcards

Altered Voiding and Urinary Obstruction Flashcards

1
Q

What are the potential sites that can cause urinary retention/incontinence?

A
  • Brain
  • Spinal cord
  • Blockages: kidney, ureters
  • Lower urinary tract symptoms: bladder, urethra, prostate, pelvic floor muscles
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2
Q

What are the categories of lower urinary tract symptoms (LUTS?)

What conditions/symptoms are included in each one?

A

Storage LUTS:

  • Incontinence
  • Urgency
  • Frequency (doesn’t necessarily mean more production)
  • Nocturia

Voiding LUTS:

  • Poor stream
  • Hesitancy
  • Dysuria
  • Intermittency
  • Double voiding
  • Retention
  • Incomplete emptying
  • Straining

Post-micturition LUTS:

  • Terminal dribbling
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3
Q

Define urinary incontinence

What are the potential impacts of incontinence?

A

Involuntary loss of urine in sufficient amount or frequency to constitute a social and/or health problem.

  • Major cause of morbidity and institutionalisation
  • QoL impact
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4
Q

Define stress incontinence

What are its causes?

A

Occurs when pressure inside the bladder becomes greater than the strength of the sphincters to keep the urethra closed.

Often occurs on effort/exertion or when coughing/sneezing.

Causes:

  • Pregnancy/obesity (raised intra abdominal pressure)
  • Post child bearing: bladder neck hypermobility/ pelvic floor muscle weakness
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5
Q

Define urge incontinence

What are the causes?

A

Involuntary urinary leakage accompanied/preceded by an abrupt urge to void that is difficult to control.

Most common cause of urinary incontinence >50 years old.

Causes:

  • Usually idiopathic
  • Overactive bladder
  • Infection
  • Bladder stones
  • Bladder cancer
  • Stroke
  • Dementia
  • Parkinson’s disease
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6
Q

Define overflow incontinence

What can it be caused by?

A

Prolonged problems with bladder emptying lead to chronic urinary retention and detrusor muscle failure. Pressure eventually rises due to tissue overdistention and leakage occurs.

Causes:

  • Enlarged prostate
  • Bladder stones
  • Constipation
  • Spinal cord injury
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7
Q

Define functional incontinence

What can it be caused by?

A

Incontinence as the result of something not involving the urinary tract.

Causes:

  • Mobility problems
  • Dementia
  • Diuretics
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8
Q

What focussed questions should be asked when taking a history to quantify urinary symptoms?

A
  • Precipitating events, duration
  • Medical/surgical history
  • Medications
  • Pad usage
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9
Q

What clinical examinations should be carried out on a person with incontinence?

A
  • Pelvic
  • Abdomen
  • Digital rectal exam
  • Neurological
  • Mental state
  • Mobility
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10
Q

What clinical investigations should be carried out for a person with incontinence?

A
  • Urine dipstick/ MSU
  • Urine MC&S
  • Cytology
  • FBC, U&Es, glucose
  • Frequency-volume chart
  • Cystometry
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11
Q

Define urodynamics

A

Study of pressure and flow during storage, transport and expulsion of urine in the lower urinary tract.

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12
Q

How does outflow cystometry work?

A

Urethral catheter is inserted into bladder and transducer into the rectum.

  • Bladder is filled with fluid and pressures recorded in bladder and rectum
  • Bladder emptied and pressures recorded

Bladder pressure = combined abdominal and detrusor pressure

Detrusor pressure = bladder pressure - rectum pressure

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13
Q

How is continuous incontinence treated?

A
  • Urinary catheter
  • Surgery
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14
Q

How is stress incontinence treated?

A
  • Pelvic floor training
  • Surgery
  • Incontinence protection
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15
Q

How is urge incontinence treated?

A
  • Avoid stimulants to detrusor muscle
  • Bladder retraining
  • Anticholinergics: Oxybutynin
  • Surgery
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16
Q

How is urinary retention treated?

A

Restore bladder emptying:

  • Intermittent self-catheterisation
  • Surgical treatment of outflow obstruction
  • Long term catheterisation
  • Alpha blockers: Doxasozin
17
Q

What are the potential causes of urinary retention?

A
  • BPH
  • Prostate cancer
  • Prostatitis
  • Haematuria causing clots (?bladder cancer)
  • Tumours
  • Bladder stones
  • Anatomical/ neurological/ structural
18
Q

What is benign prostatic hyperplasia?

What are the symptoms?

A

Benign enlargement of the prostate gland (usually transitional zone)

Can compress urethra causing urinary retention

Can be caused by reduced apoptosis and/or increased proliferation.

Symptoms:

  • Hesitancy when urinating
  • Difficulty/taking a long time to pass urine
  • Weak urine flow
  • Stop-start flow
  • Urgency/increased frequency
  • Urinary incontinence
  • Feeling of incomplete emptying
19
Q

What tool is used to assess potential prostate symptoms?

A

International prostate symptom score

7 symptom questions:

  1. Frequency
  2. Nocturia
  3. Urgency
  4. Hesitancy
  5. Poor stream
  6. Intermittency
  7. Incomplete emptying
20
Q

What clinical examinations/investigations can be carried out to diagnose prostate problems?

A

PSA (prostate specific antigen). If raised can indicate:

  • BPH
  • Prostate cancer
  • Can be raised following digital rectal exam
  • UTI

Abdominal exam

Digital rectal exam

Transrectal ultrasound scan

21
Q

How is BPH managed?

A

Watch and wait

Lifestyle adaptations:

  • Less alcohol, caffiene and fizzy drinks
  • Limit intake of artificial sweeteners
  • Exercise

Drugs:

  • Selective a1 blocker: doxasozin

Surgery:

  • Transurethral resection of the prostate (TURP)
22
Q

What would a healthy prostate gland feel like on a digital rectal exam?

A

Smooth

Symmetrical

Even

Soft

23
Q

What would prostate cancer feel like on digital rectal examination?

A

Hard

Lumpy

Asymmetrical

Irregular

24
Q

What are the complications of BPH?

A

UTI, Acute Urinary Retention (which can cause kidney damage) & Incontinence/ Erectile problems post surgery

25
Q

How are urinary tract stones formed?

A

Formed as urine is supersaturated with salt. Crystals form which aggregate to form stones. Particle retention (e.g. in stasis) is required in order for a stone to form.

  • Crystal growth depends on degree of saturation
  • Crystal aggregation depends on collision of small crystals in the urine.
26
Q

What are the common locations for urinary tract stones to become lodged?

A
  • Pelvic ureteric junction
  • Pelvic brim
  • Vesicoueteric junction
  • Bladder urethral outlet
27
Q

What are the different types of urinary tract stones?

What type of imaging can be used to detect them?

What shapes are they usually?

A

Calcium oxalate/phosphate stones

  • X-ray
  • Large and smooth/ spiky and rough

Struvite stones

  • X-ray
  • Smooth, brown and softer than other types of stone

Cystine stones

  • X-ray
  • Crystal shaped, yellow, often staghorn shaped

Uric acid stones

  • Ultrasound and CT
  • Horn shaped and large
28
Q

How are calcium oxalate stones formed?

A

Caused by:

Hypercalciuria:

  • Idiopathic
  • Rare genetic disorders
  • Hyperparathyroidism
  • Malignancy
  • Sarcoidosis

Hyperoxaluria:

  • Primary: genetic
  • Secondary: dietary/enteric
29
Q

What are the risk factors for struvite stones?

A

All related to UTIs:

  • More common in females (higher risk of UTI)
  • Indwelling catheters
  • Neurogenic bladders
  • Urinary tract abnormalities
  • Stagnant urine
30
Q

How are cystine stones formed?

A

Caused by rare autosomal recessive tubular disorder causing cystinuria

  • Cystine not reabsorbed- crystalises
  • Occurs in young people
  • Causes multiple stones
31
Q

How are struvite stones formed?

A

Struvite stones

  • ​Form in alkaline urine that contains ammonia
  • Caused by infection from urea-splitting bacteria (proteus mirabilis, klebsiella, pseudomonas)
  • Urea is split into NH3 and CO2 by urease
  • Causes precipitation of magnesium, ammonium and phosphate to form stone (often staghorn shape)
32
Q

How are uric acid stones formed?

A

Accumulation of uric acid in urine from purine metabolism (protein, esp. red meat), alcohol.

Gout (uric acid deposits)

Associated with hyperuricaemia and/or hyperuricosuria

33
Q

How do urinary tract stones present?

A

Pain:

  • Often ‘loin to groin’ pain (ureteric colic)
    • Pelvis refers to loin and back
    • Lower ureter refers pain to testis and labium majus
    • Lowest pelvic part of ureter refers pain to tip of penis or perineum
  • Can radiate to testicles

Haematuria

Vomiting

Irritative voiding symptoms

Important to exclude leaking AAA, pancreatitis, pyelonephritis, diverticular disease.

34
Q

What initial investigations should be carried out on suspicion of urinary tract stones?

A
  • History:
    • Any stones passed
      • Previous stones?: type, age at onset, interventions
  • Urine dipstick
  • Urine MC&S
  • U&Es, calcium, urate
  • If fever: WCC, CRP
  • Imaging:
    • Urgent
    • If fever: immediate (?pyelonephritis)
    • X-ray KUB
    • USS KUB
    • CT KUB
35
Q

What is the managment/ how are kidney stones removed?

A

Remove the stone- immediately if there an infected/ obstruted kidney

Methods:

  • Extracorporeal shockwave lithtripsy- US shockwave –> Fragmentation
  • Ureteroscopic removal
  • Percutaneous Nephroliothotomy (kidney punctured using US/ Xray guidance- stones removed/ fragmented)

Block 1- Kim (17 decks)

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