LUTS Flashcards by Callum Donoher

What are the 3 categories of LUTs?

Storage
Voiding
Post micturition

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What are some storage LUTs?

Urge incontinence
Urgency
Frequency
Nocturia

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What are some voiding LUTs?

Hesitancy
Poor flow
Incomplete emptying
Terminal dribble

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What is a post micturition LUTS?

Post micturition dribble

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What is considered nocturia?

Waking up more than once to urinate

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What is nocturnal polyuria?

When you pass 1/3 or more of your urine output at night

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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

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What is the most common cause of LUTS in men and why?

BPH

BPH eventually leads to bladder outlet obstruction

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Which part of the prostate is typically affected by BPH?

Transitional zone

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How is BPH diagnosed?

Histologically (needs biopsying)

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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

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What are the 3 categories you typically have in terms of treatment for any condition?

Conservative
Medical
Surgical

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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

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What is the first line drug for treating BPH?

Tamsulosin

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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

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What is an important side effect of tamsulosin?

Postural hypotension
(Blocks alpha 1 receptors in blood vessels preventing their smooth muscle. contraction)

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What medication do you give alongside tamsulosin if it isn’t effective in treating BPH?

Finasteride

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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

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What are some side effects of finasteride?

Erectile dysfunction
Gynaecomastia

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What is the surgical management of BPH?

TURP
Transurethral Resection of Prostate

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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

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What are the typical investigations when investigating LUTS?

Abdo exam
External genitalia exam
DRE
Urine dip
U+Es
FBC
PSA
Freq-vol chart

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What are the RED FLAG questions/symptoms you should be asking someone with LUTS?

Haematuria
Weight loss
Recurrent UTIs

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What is overactive bladder syndrome?

Urgency, frequency + or - urge incontinence often accompanied by nocturia

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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