Female LUTS

Question 1

Presentation of female LUTS

Answer 1

-Storage Symptoms: Frequency, Urgency, Nocturia, Urge UI
-Voiding Symptoms: Hesitancy, Straining, Intermittency, Poor Stream, Terminal Dribbling, Sensation of Incomplete Emptying

-Related Conditions & Complications:
=Urinary Incontinence
=Urinary Retention: AUR, CUR
=Recurrent UTIs
=Bladder Stones
=Haematuria

-Obstructive Uropathy/Nephropathy: HDN + AKI
-NB Obstructive uropathy is much rarer in women than men, as they do not have a prostate

Question 2

Focused female LUTS history

Answer 2

-LUTS: storage LUTS, voiding LUTS, UI
-SUI, UUI, Mixed UI

-Provocative manouevres: running tap, key in latch, standing
-Quantify UI: panty liners vs pads (how many?), changes of clothing
-RFs for UI: caffeine, MS, spinal injury, CVA, multiparity, obesity, pelvic surgery

-Enquire: BO - ?constipation, ?? Faecal incontinence
-CCF, CKD, DM, CVA, Sp injury, MS, Parkinson’s, pelvic surgery
-Medication (alpha-blockers, diuretics, opiates), EtOH

Question 3

Female LUTS: examination

Answer 3

-Abd: ?palpable bladder, pelvic masses

-Perineum:
-Cough test positive (for UI)?
-Vaginal tone (weak?): Oxford test
-Urethral diverticulum
-Prolapse
-Vaginal atrophy
-Fistula

-Neuro: LL examination (incl anal tone + peri-anal sensation) esp if no precipitating cause of AUR(may well be a presentation of MS)
-Legs: ?peripheral ankle oedema (esp with Nocturia)
-UA: urinalysis: ?UTI

Question 4

Female LUTS: further assessment

Answer 4

-UA: urinalysis: ?UTI
-ICIQ Questionnaire for UI: optional

-Bloods: U+E (if palpable bladder or hydronephrosis)
-Post Void Residual: BS (PVR) if patient has voiding difficulty
-Bladder Diary: to determine fluid input, voiding pattern, freq of UI
-Pad Test: if quantification of leakage is desired
-Pelvic USS: to exclude pelvic mass lesion as cause of unexplained AUR
-Consider spinal MRI: to exclude spinal lesion for unexplained AUR
-Consider CMG (Urodynamics): for SUI, UUI, or if detrusor overactivity suspected

Question 5

Conservative/ Lifestyle measures

Answer 5

-Restriction of EtOH, Caffeine, Evening fluids
-Cessation of Smoking
-Weight Loss
-Avoidance of cold environment (cold reduces ADH release and precipitates freq)
-Optimisation of contributing medical problems: LVF, CKD, DM,OSA
-PFME (Pelvic Floor Muscle Exercises)

Question 6

Pharmacological Rx Storage for female LUTS

Answer 6

-Antimuscarinics: Solifenacin, Fesoterodine, Oxybutynin
-Antimuscarinic SEs: dry eyes, dry mouth, constipation, confusion… may also precipitate urinary retention invulnerable patients
-Mirabegron (Betmiga®; beta 3-adrenoreceptor agonist): fewer SEs, better tolerated

Question 7

Overview of Female LUTS

Answer 7

-Assessment: Hx, Examination, DVE, LL Neuro, UA, PVR (BS)

-Lifestyle Changes:
=Restriction of Caffeine / EtOH / Evening fluids
=Cessation of smoking, Weight Loss
=Optimisation of contributing medical problems: LVF, CKD, DM, OSA
=PFMEs
=Bladder Training (Bladder Drill for Frequency, Timed Voiding for Lazy Bladder, Entrapment techniques for SUI)

-Medical Rx:
=Antimuscarinics for Storage LUTS: Solifenacin, Fesoterodine, Oxybutynin
=Mirabegron (Betmiga®; beta 3-adrenoreceptor agonist): fewer SEs,

-Failed Medical Rx (No improvement LUTS, or if SEs of Rx intolerable):
=consider CMG/VCMG (Urodynamics): subsequent Mx determined by underlying Dx (refer to UI tutorial/lecture for more details: eg Intradetrusor Botulinum toxin (Botox) therapy for DOA; Autologous sling for SUI)

Question 8

Overview of female LUTS: AUR

Answer 8

-Causes Female AUR:
=Trauma: Pain
=Infection: UTI
=Neoplasm: Pelvic tumour
=Constipation
=Immobility
=Urethral stricture
=Neuro: MS, Sp cord injury, CVA, Neuropathic bladder, DM, prev pelvic surgery
=Medication: Antimuscarinics, TCAs, Antipsychotics, Opioids (constipation), BDZs, EtOH

-Assessment
=Post Void Residual: BS (PVR) if patient has voiding difficulty
=Pelvic USS: to exclude pelvic mass lesion as cause of unexplained AUR
=Consider spinal MRI: to exclude spinal lesion for unexplained AUR
=Consider CMG (Urodynamics): if neuropathic (underactive / hypotonic bladder) suspected

-Mx
=Depends on underlying cause
=Mobilisation, bowel clear out
=Assessment / revision of current medication
=Cystoscopy + Urethral Dilatation if urethral stricture suspected
=Pessary for obstructing prolapse
=ISC for underactive bladder

Question 9

Describe urodynamic assessment

Answer 9

-Pressure transducers
=Bladder
=Rectum

-Pressure from bladder and rectum measured during filling and voiding
-Patient asked to cough periodically
-Subtracting rectal (abdominal)pressure from bladder = detrusor activity