LUTS

Question 1

What are the clarifications of BOO

Answer 1

Congenital/Acquired
Partial/Complete
Acute/Chronic/Acute on Chronic.

Question 2

List examples of congenital BOO

Answer 2

Phimosis
Paraphemosis

Congenital Urethral divertoculum
Congenital Urethral Stricture Complete/Partial
Congenital Ureterocoele
Anterior Uretral valve
Posterior Urethral valve

Meatal stenosis
Congenital bladder neck obstruction/stenosis

Question 3

List the inflammatory causes of BOO

Answer 3

Inflammatory causes
- Cystitis
- prostitis
- urethritis

Trauma
To the
- Bladder
- Prostate
- Urether
- Brain
- Spine
- Pelvic Bone

Neoplasia
Benign:
- Polyp in the bladder and Urethral
- BPH
Malignant:
Of the bladder, urether, prostate
- Rectal tumor
- Cervical cancer

Metabolic
- DM complications
Stone in the:
- Bladder
- Urether

Messalinous
- Foreign body in LUT
- Cervix cancer
- Severe Constipation
- Pregnancy

Question 4

What are the complications of BOO?

Answer 4

Hemorrhoids
Urinary stones
Sepsis
CKD
Anemia
Uremia

Question 5

What are the complications of BOO? Inflammatory complications

Answer 5

Inflammatory Complications:

1. Recurrent Urinary Tract Infections (UTIs):

• BOO can cause urine stasis (urine not being completely emptied from the bladder), which provides a breeding ground for bacteria, leading to recurrent infections. These infections can affect the bladder (cystitis) or even ascend to the kidneys (pyelonephritis).

2. Cystitis (Bladder Inflammation):

• Chronic irritation and incomplete bladder emptying can lead to inflammation of the bladder lining. This can present as frequent, painful urination, and a feeling of incomplete voiding.

3. Prostatitis (in males):

• Inflammation of the prostate gland may occur secondary to BOO, particularly when the obstruction is related to prostatic hyperplasia or other prostate disorders.

4. Urethritis:

• Inflammation of the urethra can develop due to irritation from prolonged straining to urinate or secondary infections.

5. Balanoposthitis (if BOO is associated with phimosis or other foreskin issues):

• In males, poor hygiene or infections related to difficulty urinating due to BOO can lead to inflammation of the glans and foreskin.

Question 6

What are the complications of BOO? Non Inflammatory complications

Answer 6

Non-inflammatory Complications:

1. Hydronephrosis:

• This occurs when urine backs up into the kidneys due to the obstruction, leading to swelling of the renal pelvis and calyces. It can cause kidney damage if left untreated, leading to chronic kidney disease.

2. Bladder Stones:

• Incomplete emptying of the bladder can lead to the formation of bladder stones, which occur as minerals crystallize from the retained urine. These stones can further aggravate obstruction and cause additional symptoms like pain, blood in urine, or infections.

3. Chronic Kidney Disease (CKD):

• Prolonged BOO, especially when associated with hydronephrosis or recurrent infections, can lead to permanent kidney damage and chronic kidney disease.

4. Bladder Diverticulum formation:

• The increased pressure within the bladder from straining to urinate can cause outpouching of the bladder wall, forming diverticula. These pouches can harbor infections, stones, and may cause further obstruction.

5. Bladder Wall Hypertrophy and Trabeculation:

• Over time, the bladder wall thickens and becomes less compliant due to increased muscle activity in response to obstruction. This makes the bladder less effective at expelling urine and can contribute to further complications.

6. Acute or Chronic Urinary Retention:

• BOO can lead to complete or partial inability to empty the bladder, resulting in painful urinary retention. Chronic retention may be associated with overflow incontinence, where small amounts of urine leak out due to a full bladder.

7. Vesicoureteral Reflux (VUR):

• Increased bladder pressure can cause urine to flow backward from the bladder to the kidneys, increasing the risk of kidney infections and damage.

Question 7

What are the clinical features of BOO?

Answer 7

Obstructive and Irritating

1. Irritative Symptoms (FUN):
   
   • Frequency: Increased need to urinate during the day or night (nocturia).
   • Urgency and Urge Incontinence: Sudden, intense urge to urinate, sometimes leading to leakage.
   • Nocturia: Waking up at night to urinate, often a sign of incomplete bladder emptying.
2. Obstructive Symptoms (WISH RIDO):
   
   • Weak Stream: Urine flow is weaker than normal.
   • Intermittency: Start-and-stop pattern of urine flow.
   • Straining: Increased effort during urination, which may not improve flow.
   • Hesitancy: Delay in initiating urine flow.
   • Retention: Episodes of inability to urinate (acute retention) or residual urine after voiding (chronic retention).
   • Incomplete Voiding: Feeling that the bladder has not emptied completely.
   • Dribbling: Terminal dribbling or slow dripping of urine after voiding.
   • Overflow Incontinence: Involuntary leakage of urine due to overfilled bladder

Answer 8

When taking a history for Bladder Outlet Obstruction (BOO), a structured approach is essential. The goal is to determine the cause of the obstruction, understand the symptoms and their impact on the patient’s life, and identify any complications. Here’s how to gather the relevant information:

Clinical Case Discussion

Important Biodata
- Age: Certain age groups are at higher risk for specific causes of BOO, such as Benign Prostatic Hyperplasia (BPH) in older men.
- Occupation: Some professions or work habits can influence the risk of urinary issues, e.g., prolonged sitting.
- Residence: Assess if the patient lives in an area with limited access to healthcare.
- Sex: Male patients are more prone to BOO due to prostate-related causes.
- Tribe/Race: Some genetic predispositions or cultural factors may affect the risk of BOO.

Common Presenting Complaints
- Difficulty in Passing Urine: Ask about how long it takes to start urinating, stream strength, and completeness of voiding.
- Inability to Pass Urine: Acute urinary retention, where the patient cannot urinate, may indicate a severe blockage.
- Features Suggestive of Metastasis: Includes symptoms such as low back pain and difficulty walking.
- Features of Obstructive Uropathy:
- Increased Urinary Frequency: Frequent need to urinate, especially at night.

History of Presenting Complaints

Symptom Analysis – Lower Urinary Tract Symptoms (LUTS)
Divide LUTS into irritative and obstructive symptoms:

.

3. Associated Symptoms:
   
   • Dysuria: Pain or discomfort during urination, often linked to infection.
   • Hematuria: Blood in urine; ask if it is at the beginning, end, or throughout urination, and if it is painful or painless.

History of Etiology/Differentials
The goal is to rule out other conditions that can cause or mimic BOO.

1. Rule Out Urethral Injury or Stricture:
   
   • Preceding Trauma: History of trauma, such as pelvic fractures or a fall astride, may cause strictures.
   • Urethral Surgery or Instrumentation: Previous procedures, including catheterization, may have led to scarring.
   • Previous Urethritis or Discharge: History of sexually transmitted infections or urethritis can lead to strictures.
2. Rule Out Prostate Cancer:
   
   • Symptoms of Malignancy: Weight loss, anorexia, low back pain, rectal bleeding, paraparesis or paraplegia.
   • Family History: Ask if there’s a family history of prostate cancer or benign prostatic hyperplasia (BPH), as this increases risk.
3. Rule Out Diabetes Mellitus (DM):
   
   • Symptoms of DM: Polyphagia (increased appetite), polydipsia (increased thirst), and polyuria can indirectly impact the urinary tract.
   • Diuretic Use: Diuretic medications can increase urinary frequency and worsen symptoms.

History of Complications
These complications can arise due to long-standing BOO:

1. Fever: Suggests infection such as urinary tract infection (UTI) or prostatitis.
2. Metastasis Symptoms (if cancer is suspected):
   
   • Bone Pain and Paraplegia: Signs of bone metastasis.
   • Cough and Hemoptysis: Possible lung involvement.
   • Neurological Symptoms: Headache, drowsiness, or neurological deficits.
   • Jaundice and Abdominal Pain: Potential liver metastasis.
   • Fatigue and Lethargy: Symptoms that may indicate anemia, common in malignancy.
3. Features of Uremia/Uropathy: Accumulation of waste products in blood due to urinary obstruction.
4. Hernia Formation and Hemorrhoids: Result from chronic straining due to difficulty in urination.

This systematic approach to history-taking allows for a comprehensive assessment of bladder outlet obstruction, identifying possible causes, symptoms, and complications to aid diagnosis and management.

Question 9

What are the possible complications of BOO
&
Differential diagnoses

Answer 9

A Case of Benign Prostatic
Enlargement/hyperplasia

Differential diagnoses of BPH
Cancer prostate,
Urethral stricture,
Bladder ncck stenosis,
Cancer bladder,
Bladder calculus,
Neurogenic bladder,
Diabetes mellitus,
Depression

Complications of BPH
• Retention of urine: acute or chronic
Recurrent UTI
Bladder Diverticula
Hydrourcter and Hydroncphrosis
Calculi formation
Hacmaturia
Progressive renal failure
Effects on quality of life e.g. poor slcep, recreation, erectile function

NOTE the following points:
> In acute retention, the patient is unable to pass urine despite urge with associated suprapubic
pain and fullness-urethral catheterisation should be done
> In chronic retention, the patient still passes small quantity of urine but always have some
retained (the residual volume is >25Omnl; whereas normal is about 5Oml). They may present
with overflow incontinence, enuresis and renal insufficiency
> Patients with chronic retention have a feeling of incomplete voiding, suprapubic fullness
however no pain-DO NOT catheterise except if above complications have set in:
> For complicated chronie retention– catheterise and conect a drip-set to slowly regulate the
Lurine low in order to avoid reactive haematuria which result from tearing of previously
engorged bladder vessels from sudden drop in the intra-vesical pressure
> Haematuria in BPH is due to engorged and friable “Prostatic varices” which are easily
eroded (by infection resulting from urinary stasis)

Question 10

CLINICAL CASE DISCUSSION
Important Biodata
*Age *Occupation
*Residence *Sex *Tribe/Racc
COMMON PRESENTING COMPLAINTS
• Difficulty in passing urine
• Inability to pass urine
• Fcatures suggestive of metastasis c.g.
Inability to walk
low back pain
• Features of obstructive uropathy
• Increascd urinary frequency
HISTORY OF PRESENTING COMPLAINTS
*Symptom Analysis - lower urinary tract symptoms (LUTS)
• Iritative: FUN
Frequency: increased frequency
Urgency, Urge incontincnce
Nocturia
Obstructive: WISH RIDO
Wcak strcam
Intermittency
Straining: usually docs not improve strcam
Hesitancy
Retention–any cpisode of acute urinary retcntion
•
Incomplete voiding
Dribbling- teminal dribbling
Overflow incontinence
• Associated symptoms
Dysuria (infection)
Hacmaturia; is it initial, total or terminal; painful or painless
*History of Actiology/Differentials–rule out other differentials of BOO
Rule out urcthral injury/stricture
Preceding trauma– pclvic fracture, fall astride, etc
Urethral surgery or instrumentation
Previous urethritis, urethral discharge
Rule out Cancer of prostate
Weight loss
Anorexia
Low back pain
Rectal blecding
Paraparcsis/ paraplegia
Family history–may be positive for both BPH and Ca P
• Rule out DM - polyphagia, polydipsia
. Diuretic usc
History of Complication
• Fever - infection, UTI, prostatitis
Metastasis -
bonc pain, paraplegia,
cough, hacmoptysis,
headache, drowsiness,
jaundice, abdominal pain,
weakness, lethargy, casily fatigued (anaemia)
Features of Uraemia/uropathy
Hemia formation
• Haemorhoids
PHYSICAI. EXAMINATION
KAbdominal cxam
Distended bladder (urinary retention),
Enlargcd liver, Check llernia orifices
Palpate ventral penis for urcthral induration(stricturc)
Do not check for urethral inhıration in a catheterised patient
*Rcctal l:Exam–Inspcction
Part buttocks and inspcct for anal hygicne, anal warts, cxternal hacmorrhoid. rectal prolapse,
scntincl tag, fissure, fistula-in-ano
Ask to bcar down obscrve for protrusion, rectal prolapse
**Digital cxam
Anal sphincteric tonc
Rectal content
Rectal wall mass–fecl prostate on anterior aspect
Rcctal wäll tenderness
Gloved finger – whether blood stain
**f Prostate is enlarged-characterise
Surface- smooth, nodular, irregular
Consistency – firm, rubbery, hard, heterogeneous
Median sulcus,- present, distorted, absent
Both lateral lobes - asymmetry, feel a nodule
Presence of lateral sulci
Tumour spread to lateral structures- winging
Palpable seminal vesicles
Rectal mucosa – mobile or fixed