Lower Urinary Tract Symptoms Flashcards by Hannah Meiklejohn

Mr White, a 73 year old man, presents with “problems with his waterworks”
What are the different bladder symptoms that patients can experience?

Obstructive: SHED (straining, hesistancy, incomplete emptying/intermittency, dribbling)
Irritative: FUND (frequency, urgency, nocturia, dysuria)

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Mr White, a 73 year old man, presents with “problems with his waterworks”
What questions are important to ask?

Symptom duration and severity
Degree of bother for patient
Any significant medical conditions and co-morbidities

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List 3 causes of obstructive urinary symptoms

BPH
Prostate Ca
Stricture

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List 6 causes of irritative urinary symptoms

Secondary to obstruction
UTI
Bladder Ca
Stone
DM
TB

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Mr White, a 73 year old man, presents with “problems with his waterworks”
What would you look for on examination?

Abdomen: palpable/percussible bladder
Genitalia: phimosis, balanitis, meatal stenosis, epididymitis
DRE: enlarged prostate (BPH or Ca), rectal mass

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Mr White, a 73 year old man, presents with “problems with his waterworks”
Further Ix?

MSU
UEC
?PSA
Bladder diary
Voiding flow rate
U/S: look for residual urine, hydronephrosis

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List 5 medical causes of LUTS

Nocturnal polyuria
Polydipsia
Drugs: caffeine, alcohol, diuretics, anti-cholinergics, sympathomimetics
DM
OSA

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How should a patient with LUTS be managed (after ruling out an underlying medical cause)?

Observation
Pharmacological treatment
Surgical treatment

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List 3 options for medical treatment of LUTS

Alpha blockers
5-alpha reductase inhibitors
Combination

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List 3 surgical options for treatment of LUTS

TURP
BNI (bladder neck incision)
Open prostatectomy

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Mr White, a 73 year old man, now presents to ED with urinary retention
What does this mean?

Sudden and painful inability to pass urine
Although most frequent urological emergency, relatively uncommon
If painless, NOT AUR

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List 3 causes of urinary retention which are NOT classed as AUR

Neurogenic (central or peripheral, e.g. DM)
Long term voiding dysfunction with decompensated detrusor
Ageing

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List some causes of urinary retention

BPH
Prostate Ca
Stricture
Neurological

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List 6 acute precipitants of urinary retention

UTI
Diuresis (including alcohol)
Constipation
Drugs (e.g. anticholinergic, sympathomimetic)
Postoperative (due to pain, anesthetic, analgesics, loss of mobility)
Bleeding (clot retention)

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List 4 neurological causes of urinary retention

DM
Stroke
PD
Acute spinal cord injury

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What is the typical Hx of urinary retention?

Usually Hx of progressive LUTS

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List 5 risk factors

Ageing
Established LUTS
Low urinary flow rate
Enlarged prostate
Raised PSA

List 4 reasons patients may develop urinary retention postoperatively

Pain
Anaesthetic
Analgesics
Loss of mobility

Describe the pathophysiology of urinary retention

Fixed component: hyperplastic tissue

Dynamic component: muscle contraction

List the 3 broad causes of urinary retention in women

Reflex AUR
Intrinsic compression
Extrinsic compression

List 2 causes of reflex AUR

Urethritis

UTI

List 4 causes of intrinsic compression in women which may lead to urinary retention

Meatal stenosis/stricture
Tumour
Urethral diverticulum
Urethral stone

List 2 causes of extrinsic compression in women which may lead to urinary retention

Severe prolapse

Pelvic space-occupying lesion

Mr White has had mild LUTS for 6/12, mainly decreased flow and nocturia
He was at a wedding reception that evening, prior to presenting in ED
How will you assess and treat him initially?

Initial Mx: brief Hx with particular attention to anything that might complicate catheterisation (PHx TURP, strictures), pass catheter
Hx: LUTS, ask about precipitants, Hx of neurological conditions, Rx
O/E: residual urine, DRE, focussed neurological examination
Ix: CSU (catheter specimen of urine) with MCS, UEC, urinary tract U/S, ?PSA

Possible findings on U/S

Prostate size | Complications (e.g. bladder calculi, hydronephrosis)

Treatment of urinary retention

Establish drainage: indwelling urethral, intermittent self catheterisation, suprapubic catheter If evidence of complicated retention: obstructive nephropathy, sepsis

Describe the appropriate procedure for passage of an IDC

Sterile technique Lignocaine Patient supine and relaxed (analgesia and confidence) Catheter sizes

Describe appropriate catheter selection for men and women, and in cases of haematuria

12-14F for men 14-16F for women 22-24F 3-way for haematuria

How do you know you have successfully placed an IDC in the bladder?

Return of urine Catheter up to the hilt NB do not inflate balloon unless sure!

What are some reasons for being unable to pass an IDC?

``` ?Hx of stricture or TURP False passage (look for evidence of trauma e.g. blood on catheter) ```

Problem-solving options if unable to pass IDC

Ask for help Try different size Other options: suprapubic catheter (U/S guided), catheter introducer (if only urologist), flexible cystoscopy and IDC insertion

What is obstructive nephropathy? How is it defined?

Back pressure from AUR sufficient to cause renal dysfunction | Defined by elevated creatinine, bilateral hydronephrosis

What is post-obstructive diuresis? What is the underlying cause? How is it managed?

>200 mL/hr for >2 hr Usually osmotic with some impaired tubular function Usually self-limiting

How is obstructive nephropathy managed?

``` Admit Monitor urine hourly Replace UO with 1/2 volume 0.9% NaCl Monitor UECs regularly Beware increased volume and Replace Mg 2+ PO4 3- as required ```

What are the treatment options for obstructive nephropathy?

Alpha-blocker and trial of void Surgery: TURP, laser, open Long term IDC/ISC (intermittent self-catheterisation)

Describe the timing for a trial of void

Simple: 2-3 days Complicated: 1-2 weeks

What is the role of alpha blockers in a TOV?

Improves success rate

What is the major downside of surgery for obstructive nephropathy?

Increased morbidity and mortality

What is a possible SE of long term IDC?

Sepsis

What is the natural Hx of TOV for obstructive nephropathy?

25-30% successful | Remainder require bladder outlet surgery

List some practicalities of giving a long term IDC

Provide leg-bag education and 2 different types of drainage bags Ensure right length of tubing for patient preferred bag position Anchor catheter (if pulls on urethral meatus will erode through, acquired hypospadias??) Consider starting on tamsulosin 0.4 mg OD Consider admission if safety issue