Lecture ILO’s

Question 1

Lower urinary tract structures

Answer 1

Kidneys
Ureters
Bladder
Prostate
Urethra

Question 2

Blood supply of the ureters

Answer 2

The upper ureter is supplied directly by the renal arteries. The middle portion is suppled by the common iliac arteries, branches of the aorta and the gonadal arteries. The latter portion is supplied by the internal iliac arteries.

Question 3

Blood supply of the bladder

Answer 3

The bladder is supplied by the superior vesical art , and the inferior vesical art which are branches of the internal iliac. In females the uterine and vaginal arteries also provide additional supply.

Question 4

Blood supply of the urethra

Answer 4

The urethra is supplied by the inferior vesical art, the middle rectal art and the internal pudendal art.

Question 5

Blood supply of the prostate

Answer 5

The prostate is supplied by the inferior vesical artery, a branch of the internal iliac (via the hypogastric)

Question 6

Anatomy of the ureters

Answer 6

Anatomy of the ureters
• Tubes of smooth muscle that move urine from the kidneys to the urinary bladder via peristalsis.
• Lined by urothelium, which responds to stretches.
• Are around 20-30cm in length.
• Run from the renal pelvis, over the psoas major to reach the brim of the pelvis, where they cross in front of the common iliac arteries and finally pass down along the sides of the pelvis and curve forwards to enter the posterior bladder (trigone) on each side.
• Have a physiological sphincter at the bladder.

Question 7

Anatomy of the bladder

Answer 7

Anatomy of the bladder
• Muscular sac that sits in the pelvis, just above and behind the pubic bone.
• Variable volume, which can change with age and certain health conditions.
• Divided into a broad fundus, a body, an apex, and a neck.
• Has three openings, that have mucosal flaps covering, which act as
valves.
• Walls have a series of thick mucosal folds called rugae, which allow for the expansion of the bladder.

Question 8

How is the bladder controlled?

Answer 8

• Stretch receptors signal the parasympathetic NS to stimulate the muscarinic receptors in the detrusor, which causes it to contract.
• Atthesametimethesympathetic nervous system causes the muscle of the trigone to relax, as well as the internal sphincter.
• Finallyweconsciously(somaticnervous system) relax the external sphincter, and expel urine.
• There is a negative feedback loop the keeps the right muscles relaxed/contracted in the correct order.
• Disruption in this order of contraction is one cause of urinary retention.

Question 9

Anatomy of the urethra

Answer 9

Anatomy of the urethra
• A fibrous and muscular tube that connects the bladder to the external urethral meatus.
• In females measures around 4cm, and in males measures between 15-25cm.
• Has two sphincters, the internal at the bladder neck and external at the urethral meatus.
• Lined by epithelium, which contains small mucous-secreting glands that lubricate the urethra.
• In men this structure passes through the penis, and is a conduit for ejaculation.

Question 10

Structure of the prostate lobe

Answer 10

Structure of the prostate
• Surrounded by an elastic, fibromuscular capsule and contains glandular tissue and well as connective tissue.
• Consists of 4 zones.
➢Peripheral zone 70%- back of the gland that surrounds the distal
urethra.
➢Central zone 25%- surround the ejaculatory ducts.
➢Transitional zone 5%-surrounds the proximal urethra and growth of this causes BPH.
➢Stroma- devoid of glandular components and consists of muscle and fibrous tissue.

Question 11

Function of the prostate

Answer 11

Function of the prostate gland
• Secretes fluid that becomes part of semen.
• Theses secretions include enzymes, prostatic acid, phosphatase, fibrinolysin, zinc and prostate specific antigen- which all essentially lead to the activation of sperm.
• It acts a switch between urination and ejaculation, by shortening and tilting vertically to allow for urination, blocking the ejaculatory ducts.

Question 12

What is benign prostatic hyperplasia and what is it caused by?

Answer 12

Benign Prostatic hyperplasia (BPH)
• A non cancerous increase in the size of the prostate gland.
• Normally the median and lateral lobes of the enlarge as these areas
contain the most glandular tissue.
• Caused by an increase in Dihydrotesterone (DHT) and estrogen and a decrease in testosterone, which unbalances cell homeostasis.

Question 13

How is benign prostatic hyperplasia treated?

Answer 13

Treated conservatively with:
Finasteride (5-alph reductase inhibitor, which decreases DHT)
Can decrease prostate by upto 20% - the difference between needing a catheter or not
Also decreases vascularity so decreases chance of a bleed

Tamsulosin (selective alpha1 receptor antagonist, which blocks the alpha 1 receptors in the bladder neck, prostate and urethra resulting in relaxation of the smooth muscle. - can also be used to treat kidney / ureter stones

Treated surgically with a TURP.
Trans urethral resection of the prostate
Shaving away the different lobes
Laser therapy is used if prostate is too big for this

Question 14

Finasteride

Answer 14

Finasteride (5-alph reductase inhibitor, which decreases DHT)
Can decrease prostate by upto 20% - the difference between needing a catheter or not
Also decreases vascularity so decreases chance of a bleed

Question 15

What is dysuria

Answer 15

Dysuria is discomfort, burning, or sensation of pain during micturition.  Patients may also complain of urethral discomfort not associated
with micturition.
Can be
external - urine irritating the inflamed genital organs
internal - pain felt in the urethra

Question 16

Infections causes of dysuria

Answer 16

UTI

Cystitis
Most uncomplicated UTIs - are caused by:

Escherichia coli
Staphylococcus epidermidis
Proteus mirabilis
S aureus

 Urethritis
 Sexually transmitted diseases
 Vulvovaginitis
 Epididymo-orchitis  Balanitis
 Prostatitis
 Cervicitis

Question 17

What makes a person more susceptible to getting a UTI?

Answer 17

Certain conditions can make a patient more vulnerable to getting a UTI and also having a more severe infection.

• bladder outlet obstruction • E.g. BPH
• urethral stricture/stenosis
• bladder or urethral diverticulum
• renal cysts
• neurogenic bladder
• E.g. multiple sclerosis
• diabetes (immuno comprimised)
• steroid use
• stroke
• spinal cord injury

Question 18

Non infectious causes of dysuria

Answer 18

 Obstructive
 BPH, stones, strictures/stenosis
 Traumatic
 Honeymoon cystitis, catheterisation, abuse, intense
exercise
 Inflammatory
 Interstitial cystitis, atrophic vaginitis, spondyloarthropathies, non infectious prostatitis , ketamine bladder
 Malignancies  Drug related
 dopamine, cantharidin, ticarcillin, penicillin-G, cyclophosphamide
 Local irritants

Question 19

What should be included in a history of a patient presenting with dysuria?

Answer 19

 Detailed history
 Duration of symptoms
 Rapid – UTI, STIs/urethritis – over days

 Sexual history – regardless of age of patient

 PMH
 Diabetes, pregnancy, inflammatory diseases, immunocompromised, recurrent UTIs
 Risk factors
 Smoking, exposure to chemicals, family history of malignancies, use of topical agents

 Drug history
 Travel history
 Surgical history

Examination:
Vital signs (sepsis)
 Abdominal exam
 Examination of the genitalia
May include swabs or if history is suggestive of STI refer to GUM clinic
PR/prostate exam

Question 20

Investigations for a patient presenting with dysuria

Answer 20

Investigations:
Urine dipstick - leukocytes + nitrates = v likely UTI

Question 21

What aetiologies can cause haematuria?

Answer 21

What aetiologies can cause haematuria ?
 Infection
 Trauma
 Cancer
 Coagulopathies
 Inflammatorydiseases
 Auto immune diseases
 Congenital disease or malformations
 Medications – phenazopyridine, rifampicin, phyentoin, levodopa, quini ne
 Food (pseudo)

Question 22

What is haematuria?

Answer 22

Haematuria (Blood in the Urine)
 Haematuria is the term used to describe blood in the urine

 It most commonly presents in very small quantities (microscopic haematuria) and is only detected by simple dipstick testing of urine sample.(in primary care)

 Much less often, visible blood may appear in the urine as a brown or red discoloration of the urine.

 Haemoglobinuria is the presence of free haemoglobulin in the urine (haemolytic anaemia) - pigment is from the breakdown of blood

Question 23

Common causes of non visible haematuria

Answer 23

Kidneys
Pyelonephritis Nephrolithiasis Trauma

Ureter
Infection, trauma

Bladder
Trauma (sexual activity, exercise, contusion)

Urethra
Cystitis (UTI)

Endometrium
Endometriosis

Prostate
Acute prostatitis
Benign prostatic hyperplasia (BPH)

Vagina/labia
Menstruation
Trauma (sexual activity, exercise, contusion)

Question 24

Common causes of visible haematuria

Answer 24

Kidneys
Pyelonephritis
Kidney stone
Post-infectious glomerulonephritis (check if recent infection)
Cancer

Ureter
Infection

Bladder
Bladder cancer Trauma

Urethra
Cystitis (UTI)
Instrumentation of urinary tract

Endometrium
Endometriosis

Prostate
Benign prostatic hyperplasia (BPH) Prostate cancer

Vagina/labia
Menstruation
Trauma (sexual activity, exercise, contusion)

Question 25

Investigations for haematuria

Answer 25

Dipstick investigation to include the following

 Nitrites (bact. infection)
 Leucocyte esterase
(WCC)(query infection)
 Haemoglobin
 Protein (albumin)
 Glucose(suggests serum glucose >10mmol/L
 pH (range 4.5 to 8) blood acidosis would result in renal compensation & acidifying the urine.

Question 26

Important things to include on a physical examination for dysuria

Answer 26

 Abdominal examination to include palpation of bladder for tenderness and urinary retention

 Ballot (palpate) the kidneys by pushing the kidneys back and forward between your hands in the patient’s costophrenic angle (renal carcinoma and polycystic kidney disease)

 Digital rectum examination to identify any rectal masses (possible anterior invasion) and prostate gland for tenderness (prostatitis) , masses and size plus texture

Respiratory system – crepitations consistent with pulmonary haemorrhage, pleural effusions from fluid overload

Cardiac auscultation – endocarditis, AF with fast ventricular response

Examine finger nails for splinter haemorrhages and nail bed infarcts for vasculitis and endocarditis

Examination of the eyes including fundoscopy, Roth spots (retinal haemorrhages with white/pale centres)

Skin rashes – purpuric rash of vasculitis

Joints – arthritis and synovitis

Undertake a neurological assessment

Question 27

What blood tests should be done for haematuria

Answer 27

 Full blood count to help establish amount of blood loss - check haemoglobin/ anaemia picture as well as infection markers
 Urea & electrolytes to check for kidney function (eGFR)
 Clotting screen to check for any coagulopathy
 BM (sugar) with a HbA1C
 Autoimmune screen to check if suspect possible glomerulonephritis.
 PSA blood test in men with possible prostate problems

Question 28

Further referred investigations for haematuria

Answer 28

 An ultrasound scan of your kidneys and bladder.
 CTKUB to look for calculi (kidney stones)
 Cystoscopy
 Urodynamictests.

Question 29

Risk factors for urinary tract malignancy

Answer 29

Age greater than 40 years
Male sex
Smoking History
Prior exposure to carcinogens**(occupation) ** carcinogenic benzenes & aromatic amines
Previous pelvic radiation
Irritative urinary tract symptoms including urgency, frequency or dysuria
History of urological pathology and treatment
Cyclophosphamide (chemo)
Analgesia misuse
Schistosomiasis (worms)

Question 30

Prostate cancer referral criteria

Answer 30

Prostate cancer:

• Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their prostate feels malignant on digital rectal examination. [2015]
• Consider a prostate-specific antigen (PSA) test and digital rectal examination to assess for prostate cancer in men with:
  • any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention or • erectile dysfunction or
  • visiblehaematuria.[2015]
  Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their PSA lev els are abov e the age-specific reference range. [2015]

Question 31

Bladder cancer referral criteria

Answer 31

Bladder cancer
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer if they are:
• aged 45 and over and have:
•unexplained visible haematuria without urinary tract infection
•nonvisible haematuria that persists or recurs after successful treatment of urinary tract infection, or
•aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test. [2015]
Consider non-urgent referral for bladder cancer in people aged 60 and ov er with recurrent or persistent unexplained urinary tract infection. [2015]

Question 32

Renal cancer referral criteria

Answer 32

Renal cancer
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for renal cancer if they are aged 45 and over and have:
•unexplained visible haematuria without urinary tract infection or
•visible haematuria that persists or recurs after successful treatment of urinary tract infection. [2015]

Question 33

What is benign prostatic hyperplasia?

Answer 33

Benign prostatic hyperplasia (BPH): caused by hyperplasia of the stromal and epithelial cells of the prostate, presents with lower urinary tract symptoms (LUTS)
Common in men over 50

Question 34

Symptoms of BPH

Answer 34

Symptoms
• Hesitancy
• Weak flow
• Urgency
• Frequency
• Intermittency
• Straining
• Terminal dribbling
• Incomplete emptying
• Nocturia - significant usually if waking up twice or more
*IPSS - scoring system used to assess severity of LUTS

Question 35

Investigations for suspected BPH

Answer 35

Investigations
• Digital rectal exam - assess size, shape and characteristics of prostate
• Abdo exam - palpable bladder or other abnormalities
• Urinary frequency volume chart - recording 3 days of fluid intake and output
• Urine dipstick - assess for infection, haematuria etc
• PSA - prostate cancer

Question 36

Management of BPH

Answer 36

Management

• Mild symptoms
○ alpha blockers (tamsulosin) - relax smooth muscle, improve symptoms
○ 5-alpha reductase inhibitors (finasteride) - reduce size of prostate

• Severe symptoms - potentially require surgical options

○ Transurethral resection of the prostate (TURP)
§ Removal of part of the prostate from inside the urethra

○ Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
§ Rollerball electrode rolled across prostate, vaporising prostate tissue and creating more expansive space for urine flow

○ Holmium laser enucleation of the prostate (HoLEP)
§ Laser used to remove prostate tissue, creating more expansive space for urine flow

○ Open prostatectomy via abdo or perineal incision
§ Open procedure to remove prostate

Question 37

Describe acute urinary retention

Answer 37

Acute urinary retention: new onset inability to pass urine leading to pain and discomfort, with significant residual volumes.
· Usually due to enlarged prostate leading to bladder outflow obstruction
· Most common cause: BPH

Question 38

Common causes of acute urinary retention

Answer 38

Causes
· UTI - cause urethral sphincter to close, especially in BPH individuals
· Constipation - through compression on the urethra
· Severe pain - medications e.g. anti-muscarinics, spinal/epidural anaesthesia can affect innervation to the bladder
· Neurological - peripheral neuropathy, iatrogenic nerve damage during pelvic surgery, multiple sclerosis, Parkinson’s, DSD

Question 39

Symptoms of acute urinary retention

Answer 39

Symptoms
· Acute suprapubic pain
· Inability to micturate
· UTI infection
· LUTS symptoms as above

Question 40

Investigations of suspected acute urinary retention

Answer 40

Investigations
· Bedside bladder scan - volume of retained urine
· Routine bloods - FBC, CRP, U&Es, catherised specimen of urine (CSU)
· Ultrasound of urinary tract - if high pressure retention, assess presence of hydronephrosis

Question 41

Management of acute urinary retention

Answer 41

Management
· Immediate urethral catheterisation - measure volume drained post-catheterisation
· Treat underlying cause - e.g. tamsulosin, finasteride (BPH) started if appropriate
· Check CSU - evidence of infection? Treat with Abx
· Review medications - potential contributing causes? Treat constipation if present
· Large retention volume (>1000ml)
○ Need to be monitored post-catheterisation for evidence of post-obstructive diuresis
○ No evidence of renal impairment - TWOC
§ All men with a history of chronic LUTS or a palpably large prostate should be started on tamsulosin. Can have their TWOC >72hrs after commencement.
○ If TWOC unsuccessful - recatheterise
§ Further TWOCs attempted (after longer interval in a specialist TWOC clinic)
§ Failed attempts –> long-term catheter

Question 42

Bacteriuria

Clinically significant bacteriuria

Asymptomatic bacteriuria

Urinary tract infection

Answer 42

• Bacteriuria
• Presence of bacteria in the urine (can be normal or abnormal)

• Clinically significant bacteriuria
• The term used to differentiate laboratory evidence of bacteriuria in the urine from bacteriuria that probably results from contamination during micturition.

• Asymptomatic bacteriuria
• There is significant bacteriuria in the urine without any symptoms
of infection

• Urinary tract infection
• Presence of significant bacteriuria in the urine with signs and symptoms of infection

Question 43

Sites of infection for a UTI

Answer 43

Kidney - pyelonephritis
Ureter - ureteritis
Bladder - cystitis
urethra - urethritis

Question 44

Uncomplicated UTI

Answer 44

• An infection in a structurally and functionally normal urinary tract
• Generally effecting the lower tract infection
• Higher occurrence in women than men

• Common symptoms include:
• Dysuria
• Urgency
• Frequency
• Suprapubic pain

• Treatment (non pregnant women only) – 3 days of antibiotics

Question 45

Complicated UTI

Answer 45

An infection associated with a condition, such as structural or functional abnormalities of the genitourinary tract or the presence of an underlying disease, which increases the risks of acquiring an infection or of failing therapy.

Question 46

Examples of risk factors for a complicated UTI

Answer 46

Examples of risk factors:
• Indwelling catheters, stents, intermittent catheterization
• Bladder outlet obstruction (stones and tumours)
• Urinary tract modifications (ileal loops)
• Post-operative (urological procedures)
• Renal insufficiency, transplantation and diabetes mellitus

Question 47

Natural defence mechanisms of urinary tract

Answer 47

Urine pH
Mechanical flushing of urine flow
Urothelial secretion of cytokines and chemokines - mucosal immunity

Question 48

Risk factors for UTI’s

Answer 48

• Female sex
• Coitus
• Pregnancy
• Diabetes
• Indwelling urinary catheter
• Previous UTIs
• Lower urinary tract symptoms of obstruction

Question 49

Signs and symptoms of UTI’s

Answer 49

• Dysuria
• Frequency
• Urgency
• Suprapubic tenderness
• Polyuria
• Haematuria
• Newurinary incontinence
• Loinpain
• Fever, decreased BP ect
Confusion

Question 50

Tests for UTI’s and their limitations

Answer 50

Urine culture
• Mid-stream (least contaminated)
Limitations –
• may fail to detect slow growing or difficult to grow bacteria (N. gonorrhoea).
• Unable to reliably detect pathogens present at less than 10^3 cfu/mL.
• If three or more species grown - highly suggestive of contamination.

Urine dipstick
• Only for <65 years of age.
• Nitrites and leucocytes (pyuria)

Question 51

Culture results for UTI’s

Answer 51

White Blood Cells:
>104/mL are considered to represent inflammation
no white cells present’ indicates no inflammation and reduces culture significance
pregnancy is associated with physiological pyuria

Sterile pyuria
In sterile pyuria, consider Chlamydia trachomatis (especially if 16-24 years), other vaginal infections, other non-culturable organisms, including TB or renal pathology

• Epithelial cells/mixed growth
• presence indicates perineal contamination, which reduces significance
of culture

• Red cells
• May be present in UTIs. Persistent haematuria post-UTI should be referred.

Question 52

• 45 year old Mr BT admitted with:
- Ongoing fever
- new incontinence
- new confusion

Microscopy - raised WBC
No epithelial cells
Culture - klebsiella

Do we treat Mr BT with antibiotics for a UTI?

Answer 52

Yes
Symptoms present
Raised WBC
Organism detected
Not contaminated sample (no epithelial cells)

Question 53

What does a urine dipstick test for in a suspected UTI?

Answer 53

• Test for nitrites
• produced by the action of bacterial nitrates reductase
on dietary nitrate
• important sign of a UTI although staphylococci, enterococci and pseudomonas species do not produce nitrate reductase
• Therefore absence does not exclude infection
• False positives or false negatives can occur depending on dietary intake of nitrates

• Test for leucocytes
• enzyme found in leucocyte granules
• The dipstick test has been validated against counts of 105 colony forming unites (CFUs) per ml on a single species and leucocyte counts of 103 or more per ml of urine
• In a symptomatic patient the sticks may be insensitive since a significant colony count is 1000 CFUs per ml
• Antibiotic therapy can cause a false positive test

Question 54

UTI’s and patients over 65

Answer 54

Guidelines advise that urine cultures should not be sent in older people who are asymptomatic with positive dipsticks.

•You should only send a urine for culture if the patient has
• New onset dysuria alone, or
• Two or more signs of infection,particularly:
• Fever
• A temperature 1.5°C above the patient’s normal temperature twice
in the last 12 hours
• New or worsening delirium or debility
• New suprapubic pain
• Visible haematuria
• New frequency or urgency
• New incontinence.

• Diagnosis of UTIs in this group should follow a full clinical assessment.

Question 55

• A patient presents with dysuria and frequency
• Urine is cloudy and dipstick is positive for nitrites, leukocytes
and blood
• Probably UTI

• What further information do we need from the patient before selecting an antibiotic?

Answer 55

• Allergy status?
ARE THEY ON METHOTREXATE
• The severity and duration?
• Associated symptoms?
• Is this a recurrent infection?
• Have they had previous antibiotic exposure?
• Are they immunocompromised?
• What’s there age and gender?
• Is the patient pregnant or breastfeeding?
• Are they on any medication?
• What’s the patients renal and liver function like? • Recent travel abroad?

Question 56

Name some common antibiotics for UTI’s

Answer 56

Always start with local guidelines

• Nitrofurantoin
• Trimethoprim
• Amoxicillin
• Cefalaxin
• Ciprofloxacin
• Co- amoxiclav
• Pivmecillinam
• Fosfomycin
• Gentamicin
• Meropenem
• Temocillin

Question 57

Possible causes of urinary symptoms in men

Answer 57

• UTI
• Prostatitis
• Prostate cancer
• Benign Prostate hypertrophy
• Sexually transmitted infection
• Renal calculi
• Bladder tumour
• Diabetes

Question 58

Prostatis and prostatis symptoms

Answer 58

Prostatitis
• Acute bacterial prostatitis is a potentially serious non- sexually transmitted bacterial infection of the prostate, which may be associated with epididymitis or urethritis.

• Acute prostatitis should be suspected in a man who presents with:
• A feverish illness of sudden onset.
• Dysuria, frequency, urgency, or acute urinary
retention.
• Perineal or suprapubic pain.
• Exquisitely tender prostate on rectal examination.
• Urine dipstick test showing white blood cells, and urine culture confirming urinary infection

Question 59

Prostatitis management

Answer 59

Management
• Primary care management involves
• Starting treatment immediately, while waiting for
urine culture results
• Ciprofloxacin 500mg BD for 28 days or
• Ofloxacin 200mg BD for 28 days
• Quinolone achieve higher prostate levels
• Four week course may prevent chronic prostatitis
• Offer adequate analgesia for pain relief, such as paracetamol and/or ibuprofen first-line
• Offer a stool softener such as docusate or lactulose, if defaecation is painful

• Admission to hospital should be arranged if the man is:
• Unable to take oral antibiotics
• Severely ill, or symptoms are deteriorating despite appropriate antibiotic treatment.
• In acute urinary retention — suprapubic catheterization is required (inserting a urethral catheter may spread infection through the blood)
• Consider a urology referral
• Infection is not responding
• Pre-existing urological conditions
• To exclude structural abnormalities