L12 - Lower Urinary Tract symptoms Flashcards
Dyssynergia
- Disturbance of muscular coordination.
- Results in uncoordinated and abrupt movement .
In younger men, what may be indicative of bladder outlet obstruction?
(2)
- Bladder neck dyssyngergia.
2. Static distal sphincter obstruction
In women, what may cause obstruction?
Obstruction due to urethral stricture.
Pelvic masses: ovarian or fibroids.
Benign prostatic hyperplasia
noncancerous increase in size of the prostate gland.
BPH may lead to…
- BPH may lead to benign prostatic enlargement
- compressing the urethra ?
- may lead to bladder outlet obstruction
Describe the two categories of lower urinary tract symptoms?
Storage symptoms (FUN)
- Frequency
- Urgency
- Nocturia
Voiding
- Hesitancy
- poor Urinary flow
- intermittent flow
- terminal dribbling
Bedwetting (with other symptoms) may be indicative of what?
High pressure chronic retention
What are some underlying bladder causes?
- Marked urgency
2. Bladder pain (suprapubic pain)
Describe the examination of a patient with suspected LUTS?
4
- Suprapubic palpation
- Percussion: presence of enlarged bladder
- Digital rectal examination: does prostate have a benign or malignant consistency?
- Neurological examination
Describe the pathophysiology behind benign prostatic obstruction?
- Obstruction due to increased tone of prostatic smooth muscle
- sympathetic innervation
- dynamic component - Bulk effect of enlarged prostate
What investigations may be carried out in a patient with LUTS?
Uroflowmetry - max flow rate against time.
Give an example of where a low flow rate may be indicative of something else, rather than BOO?
Could be due to an underactive detrusor muscle, rather than BOO.
- pressure head bladder able to produce is low
Can you tell whether patient has obstruction or not just from looking at flow rate?
Nope, needs more complex urodynamic investigation.
Pressure and flow need to be measured.
Ultrasonography may show?
Residual urine volume
What is the gold standard for diagnosing BOO?
Pressure flow studies
Why might it be important to also assess patients creatinine levels?
Bladder pressure can lead to increased intrarenal pressure therefore damaging kidneys.
Why is it important to also look at serum PSA?
Diagnosis of prostate cancer could also alter management of patient.
State examples of treatment options for patients with BOO?
Alpha-adrenergic blocking drug
Prostate-shrinking drug (Finasteride)
Describe what alpha blockers do in patients with BPH and LUTS?
- Large quantities of smooth muscle in prostatic stroma BPH
- Tone of smooth muscle might be a factor causing obstruction
- Relaxes muscles of bladder and around prostate
- so that you can pass urine more easily.
Describe why might Finasteride be given?
- Inhibitor of 5-alpha reductase
- Enzyme converts testosterone to Dihydrotestosterone (androgen)
- DHT will initiate prostatic growth and subsequent development of BPH.
What treatment options may someone with High Pressure Chronic Retention have?
Prostatectomy
Longterm catheterisation.
What is a urethral stricture?
Scar within urethra
Due to inflammatory process or trauma
Summarise causes of retention in women?
- Neurological
- diabetes, MS, transverse myelitis - Non-neurological
- cystocele, rectocele, uterine prolapse, fibroids, ovarian cyst
Transverse myelitis
Inflammation on both sides of one section of the spinal cord
Cystocele
Prolapsing bladder which impinges on / obstructs urethra
Rectocele
- Herniation of front wall of rectum
- into back wall of vagina.
Definition of urinary incontinence
Involuntary loss of urine while trying to inhibit micturition
Describe innervation of lower urinary tract?
PARASYMPATHETIC - S2 to S4 SYMPATHETIC - T10 - L2 SOMATIC / VOLUNTARY - S2 to S4
What occurs during bladder filling?
- Bladder stores urine at low pressure.
- Allows kidneys to continue to produce urine.
- Sphincteric mechanism closed, providing urinary continence.
- Detrusor relaxes
What innervation causes voiding?
Parasympathetic
Simultaneous inhibition of sympathetic activity in smooth muscle of outlet of bladder.
Describe urge incontinence
- Urinary incontinence associated with extreme urgency and other filling LUTS.
- Detrusor instability
Describe stress urinary incontinence?
- Leakage of urine when intra-abdominal pressure is raised
- Found in post-partum women
- brought on by coughing and sneezing
Describe overflow incontinence
- Continual loss of urine both during the day and night
- Pelvic mass or fullness in lower abdomen
Describe continuous incontinence
caused by:
- Damage to urethral sphincter mechanism
- Urinary leakage bypasses sphincter mechanism (vesicovaginal fistula)
When is urinalysis appropriate
If UTI present.
Cytology: look out for malignant cells
Patient is incontinent at night while laying supine, however dry whilst sleeping in a chair upright…
Patient might have postural diruesis
Give examples of conservative measures for general stress incontinence
- Weight loss
- Pelvic floor exercises
- reduce caffeinated drinks
Describe how BPH may obstruct urine flow?
- Enlarged prostate pushes out against urethra and bladder
- Obstructing, blocking urine flow
- Diagnosis made histologically
Tamsulosin
Used to treat symptomatic benign prostatic hyperplasia.
Example of alpha blocker.
What are the three components of the external urethral sphincter?
- Pubo-urethral sling (part of levator ani), striated
- Urethral smooth muscle - mixed autonomic
- External sphincter - striated
Describe three parts of the urethra?
PMS
Prostatic
Membranous
Spongy (bulbar and pendulous)
Describe an intermittent stream?
Urine flow stops and starts at least once during micturition
Describe hesistancy?
Difficulty in initiating micturition, resulting in a delay in the onset of voiding after the individual is ready to pass urine.
IPSS
International prostate symptom score
- questions concerning urinary symptoms and one question concerning quality of life.
Frequency volume chart
Bladder diary.
Patient records time they get up and go to bed, fluid intake, vol of urine passed for each void. Over 3 days.
Uroflowmetry will provide information on…
Voiding time Maximum flow rate Average flow rate Voided volume Pattern of voiding curve
What may be some sid effects of taking Finasteride 5mg
Reduced libido
What may be some side effects of taking Tamsulosinn?
- Postural hypotension
- Dizziness and headaches
- Nasal congestion
- retrograde ejaculation
Postural hypotension
Form of Low BP that happens when you stand up from sitting down.
Can make people feel dizzy or light headed.
Retrograde ejaculation
Semen enters bladder isntead of emerging through the penis during orgasm.
