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MD2 Renal > Lower Urinary Tract Symptoms > Flashcards

Lower Urinary Tract Symptoms Flashcards

1
Q

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

A

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

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2
Q

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

A

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

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3
Q

List 3 causes of obstructive urinary symptoms

A

BPH
Prostate Ca
Stricture

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4
Q

List 6 causes of irritative urinary symptoms

A 
Secondary to obstruction
UTI
Bladder Ca
Stone
DM
TB
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5
Q

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

A

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

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6
Q

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

A 
MSU
UEC
?PSA
Bladder diary
Voiding flow rate
U/S: look for residual urine, hydronephrosis
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7
Q

List 5 medical causes of LUTS

A 
Nocturnal polyuria
Polydipsia
Drugs: caffeine, alcohol, diuretics, anti-cholinergics, sympathomimetics
DM
OSA
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8
Q

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

A

Observation
Pharmacological treatment
Surgical treatment

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9
Q

List 3 options for medical treatment of LUTS

A

Alpha blockers
5-alpha reductase inhibitors
Combination

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10
Q

List 3 surgical options for treatment of LUTS

A

TURP
BNI (bladder neck incision)
Open prostatectomy

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11
Q

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

A

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

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12
Q

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

A

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

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13
Q

List some causes of urinary retention

A

BPH
Prostate Ca
Stricture
Neurological

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14
Q

List 6 acute precipitants of urinary retention

A

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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15
Q

List 4 neurological causes of urinary retention

A

DM
Stroke
PD
Acute spinal cord injury

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16
Q

What is the typical Hx of urinary retention?

A

Usually Hx of progressive LUTS

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17
Q

List 5 risk factors

A 
Ageing
Established LUTS
Low urinary flow rate
Enlarged prostate
Raised PSA
18
Q

List 4 reasons patients may develop urinary retention postoperatively

A

Pain
Anaesthetic
Analgesics
Loss of mobility

19
Q

Describe the pathophysiology of urinary retention

A

Fixed component: hyperplastic tissue

Dynamic component: muscle contraction

20
Q

List the 3 broad causes of urinary retention in women

A

Reflex AUR
Intrinsic compression
Extrinsic compression

21
Q

List 2 causes of reflex AUR

A

Urethritis

UTI

22
Q

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

A

Meatal stenosis/stricture
Tumour
Urethral diverticulum
Urethral stone

23
Q

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

A

Severe prolapse

Pelvic space-occupying lesion

24
Q

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?

A

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

25
Q

Possible findings on U/S

A

Prostate size

Complications (e.g. bladder calculi, hydronephrosis)

26
Q

Treatment of urinary retention

A

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

27
Q

Describe the appropriate procedure for passage of an IDC

A

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

28
Q

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

A

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

29
Q

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

A

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

30
Q

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

A 
?Hx of stricture or TURP
False passage (look for evidence of trauma e.g. blood on catheter)
31
Q

Problem-solving options if unable to pass IDC

A

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

32
Q

What is obstructive nephropathy? How is it defined?

A

Back pressure from AUR sufficient to cause renal dysfunction

Defined by elevated creatinine, bilateral hydronephrosis

33
Q

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

A

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

34
Q

How is obstructive nephropathy managed?

A 
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
35
Q

What are the treatment options for obstructive nephropathy?

A

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

36
Q

Describe the timing for a trial of void

A

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

37
Q

What is the role of alpha blockers in a TOV?

A

Improves success rate

38
Q

What is the major downside of surgery for obstructive nephropathy?

A

Increased morbidity and mortality

39
Q

What is a possible SE of long term IDC?

A

Sepsis

40
Q

What is the natural Hx of TOV for obstructive nephropathy?

A

25-30% successful

Remainder require bladder outlet surgery

41
Q

List some practicalities of giving a long term IDC

A

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

MD2 Renal (6 decks)

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