lower urinary tract symptoms and functional urology Flashcards
what are the common storage, voiding and post micturition urinary symptoms of LUTs?
storage
- frequency
- nocturia
- urgency
- urge incontinence
voiding symptoms
- hesitancy
- poor flow
- straining
- intermittency
post mic symptoms
- sensation of incomplete emptying
- post mic dribbling
what are the common causes of male UTI’s?
- bladder outflow obstruction e.g BPH, urethral strictures
- overactive bladder e.g secondary to obstruction, infection, in situ carcinoma, radiation
- UTI
- Bladder stones
how can you distinguish bladder outflow obstruction from an overactive bladder clinically?
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how can LUTS be investigated?
- history
- abdo, genital and DRE exam
- urine dipstick
- frequency volume chart
- PSA in men
- flow rate and post mic residual volume can be done as well as urodynamics in select cases
what is uroflowmetry?
Flow rate testing. Uroflowmetry is a test that measures the volume of urine released from the body, the speed with which it is released, and how long the release takes
normal graph is bell shaped. urethral stricture will be flat and long (constant flow just takes ages) and bladder outflow issues will show a normal stream taking a long time.
IF Qmax (fastest flow rate achieved) <10mls/sec, obstruction 90% likely. if Qmax >15mls/sec, obstruction 10% likely.
how is obstruction defined and how does absent detrusor pressure differ?
by the relationship between pressure and flow.
absent detrusor pressure = detrusor failure. can be idiopathic, due to diabetes or other neurological causes, or follow on from chronic retention.
what are the components of a urodynamic study?
Filling phase
- slow, gentle rise in pressure
- phasic contractions associated with urgency = detrusor overactivity, sometimes seen in OAB
- patient asked to cough to look for stress incontinence
voiding phase
- high pressure, low flow = obstruction
- low absent pressure, low flow = detrusor failure
how can you treat BOO/BPH?
Conservative
- lifestyle advice e.g fluid intake, caffeine
medical
- Alpha blockers e.g tamsulosin relax prostatic/bladder neck smooth muscle (ADR- postural hypotension and retrograde ejaculation)
- 5 alpha reductase inhibitors reduce testosterone conversion to DHT = reduce prostatic volume, only effective in large prostates. (ADR - ED) can reduce progression of disease/ reduce need for surgery.
- anticholinergics if have OAB symptoms
surgical
- TURP/various forms of laser prostate surgery
- open retropubic prostatectomy (Rare)
how can you treat BOO/BPH?
Conservative
- lifestyle advice e.g fluid intake, caffeine
medical
- Alpha blockers e.g tamsulosin relax prostatic/bladder neck smooth muscle (ADR- postural hypotension and retrograde ejaculation)
- 5 alpha reductase inhibitors reduce testosterone conversion to DHT = reduce prostatic volume, only effective in large prostates. (ADR - ED) can reduce progression of disease/ reduce need for surgery.
- anticholinergics if have OAB symptoms
surgical
- TURP/various forms of laser prostate surgery
- open retropubic prostatectomy (Rare)
- if medication fails and complications develop e.g chronic retention (Especially high pressure) bladder stones and benign prostatic haematuria.
what is TURP syndrome?
irrigation for TURP id glycine, but absorption during long resection can lead to dilution hyponaturaemia. Get
- confusion
- fits
- visual symptoms
- coma
what is overactive bladder syndrome?
often accompanies obstruction in men, not women
urgency, with or without incontinence, often accompanied by frequency and nocturia
whats the difference between urge and stress incontinence?
stress incontinence
- provoked by coughing, sneezing, laughing, standing up
- leak a small amount
- no sensation of urge
urge incontinence
- proceeded by sensation of urgency
- can also be provoked by coughing
- can be stimulated by other things e.g running water and cold
- leak large amounts
how can OAB be treated?
conservative
- weight loss
- stop smoking
- avoid caffeine
- drink when thirsty
- pelvic floor exercise
- bladder training
medical
- anticholinergics
- topical oestrogens if post menopausal
- beta 3 agonist
surgical
- botulinum toxin I sections every 6-12 months. get risk of retention - must be able/willing to self catheterise.
- ileocystoplasty
- urinary diversion (ileal conduit)
how can stress incontinence be treated?
conservative
- weight loss
- pelvic floor exercises
surgery
- examine for prolapse, can use Tension free vaginal tape and transobturator tape as the mainstay.
- autologous slings
- urinary diversion
what can cause stress incontinence in men?
surgical injury to external sphincter/its nerve supply e.g radical prostatectomy or in TURP, or neurological problem
treatment is with an artificial sphincter or male sling
what neurological conditions can commonly effect the bladder/ sphincter function?
spina bifida
- causes neurogenic OAB and stress incontinence
Spinal cord injury
- can cause neurogenic OAB or areflexic bladder
- can cause sphincter overactivity/underactivity
some diffuse neurological conditions generally low risk of hydronephrosis/renal failure -
diabetes
- loss of sensation, overdiseantion, detrusor failure
MS
- neurogenic OAB
what is the difference between acute and chronic urinary retention?
acute
- painful inability to void
- residual volume 300-1500ml
chronic
- painless
- may still be voiding
- residual volume 300-4000ml
what are the causes of urinary retention in men?
- BPH
- Prostate cancer
- UTI
- consitpation
- neurological dysfunction
- recent surgery
- drugs
- urethral strictures
what are the causes of retention in women?
- UTI
- consitpation
- neurological dysfunction
- recent surgery
- drugs
- urethral stenosis
- pelvic masses
NB: in women do neurological exam afterwards if in retention
how is acute urinary retention treated?
- catheter and record residual voume
- history
- exam (abdo, ex genitalia, DRE)
- urine dip, U+E
- treat obvious causes e.g constipation
- alpha blocker in men
- trial without catheter 1-2 on alpha blocker, if fails TURP
what is residual volume?
Urine remaining in the bladder at the end of micturition, as in cases of prostatic obstruction or bladder atony.
what is the difference between high and low pressure urinary retention?
high pressure
- tense, thickened wall
- abnormal u&e, beware hyperkalaemia
- hydronephrosis
low pressure
- normal renal function
- no hydronephrosis
how do you treat chronic urinary retention?
- catheter and record residual voume
- history
- exam (abdo, ex genitalia, DRE)
- urine dip, U+E
monitor for post obstructive diuresis (brisk diuresis as kidney can pass urine but can not sop and you lose a lot of salt and water until you become hypovolemic and unwell)
high pressure
- can’t trial without catheter without TURP
low pressure
- TURP but only 1/2 will void again. the rest get detrusor failure and intermittent self Cath instead of TURP or if it fails. if unable to do ISC, long term catheter.
what is post obstructive diuresis?
physiological off loading of accumulated salt and water during retention that can become excessive/severe and can cause dehydration/electrolyte imbalance. needs monitoring and fluid replacement.
