functional disorders of the lower urinary tract

Question 1

what are the normal functions of the lower urinary tract?

Answer 1

• converts a continuous process of excretion ie urinary production to an intermittent process of elimination
• store urine insensibly
• void urine when it is convenient

Question 2

Give examples of storage symptoms in LUTS

Answer 2

frequency
urgency incontinence
urgency
nocturia

Question 3

give examples of voiding symptoms

Answer 3

post micturition dribbling 
hesitancy
straining 
poor/intermittent stream 
incomplete emptying 
haematuria 
dysuria

Question 4

what is dysuria?

Answer 4

painful or difficult urination

Question 5

What are the components of a history of a pt that presents with LUTS?

Answer 5

• duration of symptoms
• PMH
• past surgical history
• DH
• allergies
• symptom scoring eg IPSS
• establish the symptoms that are most bothersome to the pt - are they more storage or voiding?
• have they had treatment for it before? this may tell you the success rates for future treatments may be less
• exclude serious urology pathology - ie cancer or neurological problem
• examine the pt
• frequency volume chart
• urodynamic studies: flow rates, post-void residual volume

Question 6

how would you examine a pt with LUTS?

Answer 6

general examination for fitness for surgery
abdominal examination - enlarged bladder?
external genitalia exam
DRE
focussed neurological exam - is the anal sphincter contractility affected?
urinalysis - infection? haematuria?
ultrasound exam to look at residual volume

Question 7

What should be considered if the post void residual is high?

Answer 7

detrusor underactivity

Question 8

what two components can be dysregulated in BPH?

Answer 8

• anatomic = static - ie the volume effect of a large prostate compressing the urethra
• dynamic component: where the smooth muscle of the prostate is at increased tone mediated by alpha 1 adrenoceptors

Question 9

what is the IPSS and how is it used?

Answer 9

• international prostate symptom score
• used in clinic and on the wards
• severity score for urinary tract symptoms
• seven domains and is scored out of 35
• nocturia, frequency, hesitancy, intermittency and scores them 0-5 in terms of how bothersome they are and how frequently they occur
• at the end the pt is asked to give a quality of life score - overall how do they feel about their ability to pass urine
• can monitor their treatment with IPSS score

Question 10

explain the pathophysiology of BPH

Answer 10

increase in epithelial and stromal cell numbers in the transition zone of the prostate
can be due to an increase in cell number or due to a decrease in apoptosis or both

Question 11

What investigations would you do for BPH?

Answer 11

renal biochemistry 
imaging 
PSA - if prostate feels abnormal on DRE
flow rates 
residual volume
frequwncy volume chart
TRUSS - transrectal ultrasound scan
flexible cystoscopy if there may be infection, stones, haematuria or recent onset storage symptoms 
urodynamics

Question 12

what are the complications of BPE?

Answer 12

• symptom progression
• infections
• stones
• haematuria
• acute retention
• chronic retention
• interactive obstructive uropathy

Question 13

what is the key symptom of acute retention?

Answer 13

pain!

Question 14

how much urine is there in the bladder in acute retention?

Answer 14

600ml-1L

Question 15

are the U+Es abnormal in acute urinary retention?

Answer 15

no, they are normal as it is acute and the kidneys have not had enough time to be affected

Question 16

how is the pain relived in acute retention?

Answer 16

catheterisation