LUTS Flashcards
What are the 3 categories of LUTs?
Storage
Voiding
Post micturition
What are some storage LUTs?
Urge incontinence
Urgency
Frequency
Nocturia
What are some voiding LUTs?
Hesitancy
Poor flow
Incomplete emptying
Terminal dribble
What is a post micturition LUTS?
Post micturition dribble
What is considered nocturia?
Waking up more than once to urinate
What is nocturnal polyuria?
When you pass 1/3 or more of your urine output at night
Why may a patient have nocturnal polyuria and not have a urinary tract issue?
Conditions that causes peripheral oedema lead to more fluid circulating to the kidneys when lying down in the night
What is the most common cause of LUTS in men and why?
BPH
BPH eventually leads to bladder outlet obstruction
Which part of the prostate is typically affected by BPH?
Transitional zone
How is BPH diagnosed?
Histologically (needs biopsying)
Presentation:
60y/o man
LUTS:
-weak flow
-nocturia
-frequency
-incomplete emptying
What IX would you do?
Abdominal exam
FBC
U+Es
DRE
Urine dip
Freq-vol chart
PSA
What are the 3 categories you typically have in terms of treatment for any condition?
Conservative
Medical
Surgical
What is the conservative management approach to BPH?
Don’t drink 2hrs before bed
Switch to decaf
Stop alcohol
Toilet before bed
Elevate feet as much as possible in day to urinate as much before bed as possible
What is the first line drug for treating BPH?
Tamsulosin
What is the mechanism of action of tamsulosin in treating BPH?
Alpha 1 receptor antagonist, so leads to relaxation of internal urethral sphincter and other smooth muscle around the neck of the bladder making passing urine easier
What is an important side effect of tamsulosin?
Postural hypotension
(Blocks alpha 1 receptors in blood vessels preventing their smooth muscle. contraction)
What medication do you give alongside tamsulosin if it isn’t effective in treating BPH?
Finasteride
What is the mechanism of action of finasteride?
5a reductase inhibitor
Stops conversion of testosterone into its more potent androgen DHT (dihydrotestosterone) which leads to worsening of BPH
What are some side effects of finasteride?
Erectile dysfunction
Gynaecomastia
What is the surgical management of BPH?
TURP
Transurethral Resection of Prostate
What are some questions you should ask to investigate someone with LUTs?
What LUTS?
Duration
Fluid intake
Number of kids
PMH (prostate surgery)
Dye factory worker
Coffee or alcohol
What are the typical investigations when investigating LUTS?
Abdo exam
External genitalia exam
DRE
Urine dip
U+Es
FBC
PSA
Freq-vol chart
What are the RED FLAG questions/symptoms you should be asking someone with LUTS?
Haematuria
Weight loss
Recurrent UTIs
What is overactive bladder syndrome?
Urgency, frequency + or - urge incontinence often accompanied by nocturia
What is a common presentation of overactive bladder syndrome?
40 y/o woman
LUTS:
-Freq
-nocturia
-urge incontinence
What investigations would you like to do for a woman with LUTS:
-freq
-nocturia
-urge incontinence
Urine dip
U+Es
FBC
Abdo exam
External genitalia
Freq-vol chart
(DRE and PSA if it was a man)
What is the conservative management for overactive bladder syndrome?
Reduce fluid intake (drink when thirsty)
Don’t drink 2hrs before bed
Decaf
No alcohol
Pelvic floor exercises
Bladder training
What is the first line medication give for overactive bladder syndrome?
Oxybutynin
What is the mechanism of action of oxybutynin in treating overactive bladder syndrome?
Anticholinergic
Acts on the M3 receptors of the detrusor muscle of the bladder keeping it more relaxed allowing it to fill more before needed to Urinate
What medications are used if oxybutynin doesn’t improve overactive bladder syndrome?
Always try 2 anticholingerics (so if oxybutynin doesn’t work try another)
Tolterodine
Solefenacin
What are the side effects of anticholinergics like Oxybutynin?
Dry eyes
Dry mouth
Constipation
Urine retention
Why is urine retention an important side effect of oxybutynin that patients should be aware of when treating overactive bladder syndrome?
May have to self catheterise
If anticholinergics dont work in managing overactive bladder syndrome, what medication can be given?
Mirabegron
What is the mechanism of action of mirabegron in treating overactive bladder syndrome?
B3 agonist
Leads to the detrusor muscle relaxing allowing it to fill more with urine
What are the 3 surgical management options for overactive bladder syndrome?
Botulinum toxin injection
Sacral nerve stimulation
Ileocystoplasty
What is a complication of botulinum toxin injection in treating overactive bladder syndrome?
May have to self catheterise due to bladder being too paralysed
How does ileocystoplasty treat overactive bladder syndrome?
Put some ileum into the bladder preventing detrusor contraction
What is a complication of ileocystoplasty?
May have to self catheterise
What is stress incontinence?
Increase in Intra abdominal pressure leads to urinary leakage
What is a medical treatment option for menopausal women with overactive bladder syndrome?
Topical oestrogen
What is a major risk factor for stress incontinence?
Multiparous
How is stress incontinence conservatively managed?
Weight loss
Supervised pelvic floor exercises by incontinence nurse
Smoking cessation (reduces coughing)
What is the medical management of stress incontinence?
Nothing
Duloxetine not used due to arrhythmias
What is the surgical management of stress incontinence?
Fascial sling
Artificial urinary sphincter
What is a complication associated with a fascial sling?
Risk of retention may have to self catheterise
What is classed as an acute urinary retention?
Painful inability to void with a residual volume 300-1500ml
What is classed as a chronic urinary retention?
Painless retention of urine (may still be voiding)
RESIDUAL volume 300 - 4000ml
What are some causes of urinary retention?
BPH
Prostate cancer
UTI
Constipation
Neurological dysfunction
Urethral strictures
Drugs
Pelvic mass
Recent surgery
What is the approach to a patient with who you think has acute urinary retention?
Immediate catheterisation and record residual volume
Abdo and external genitalia exam
DRE
Post catheterisation/voiding scan
Urine dip
U+Es
CRP
FBC
Catheterised Specimen of Urine (to be checked for infection)
If a man presents with acute urinary retention what medication should he be put on after catheterising?
Alpha blocker (tamsulosin)
What should be tried 1-2 weeks after being put on tamsulosin following an acute urinary retention in a man?
TWOC
Trial. Without catheter (if low residual volume its a success)
What management should be undertaken if a male has acute urinary retention and the TWOC fails after 1-2 weeks on alpha blocker?
TURP or long term catheterisation
What volume collected after catheterisation would make you suspicious of chronic retention rather than acute?
> 1000mls
What are. Some complications of acute on chronic retention?
AKI
Inc risk of UTIs and renal stones
What is high pressure urinary retention?
Chronic urinary retention where the upper urinary tracts mechanisms of preventing reflux fail which can lead to hydroureter and hydronephrosis
What is the approach to a patient with chronic urinary retention (over 1000mls drained)?
Catheterise and measure void volume and residual volume
Abdo exam
External genitalia
DREAM
Urine dip
U+Es
ULTRASOUND KUB TO ASSESS FOR HIGH PRESSURE URINARY RETENTION (HYDROURETER AND HYDRONEPHROSIS)
What is a complication that is extremely important to monitor when offloading a patient with chronic urinary retention?
Post obstructive diuresis
What is post obstructive diuresis?
When catheterising a patient with chronic retention leads to the loss of the medullary counter current gradient leading to excess water and electrolyte removal
Can you TWOC a patient with high pressure chronic retention?
Never TWOC
How is low pressure chronic urinary retention managed?
Intermittent self catheterisation
Long term catheter
Or TURP
How does high pressure chronic retention present differently to low pressure retention?
HP = abnormal U+Es (hyperkalaemia), hydronephrosis
LP = normal renal function, no hydronephrosis
What are the complications of chronic urinary retention?
UTIs
Bladder calculi
CKD
