LUTS Flashcards
What are lower urinary tract symptoms?
An array of symptoms affecting the control and quality of micturition in the lower urinary tract.
Who can be affected by LUTS?
ANYONE (Men & Women)
Who is most at risk to develop LUTS?
- Men
- Increasing age
What are the causes of LUTS in men & women?
What is the most common cause in men?
Benign prostatic enlargement (BPE) / benign prostatic hyperplasia (BPH)
What is the most common cause in women?
Lower UTI (in women over 40)
What can exacerbate / mimic LUTS?
Lifestyle factors, for example:
- Drinking fluids late at night
- Excess alcohol intake
- Excess caffeine intake
Polyuria can exacerbate / mimic LUTS
- Due to
- Diabetes mellitus, excessive fluid intake or diuretics
What are the 3 broad categorisations of LUTS?
-
Storage symptoms
- Occur when bladder should otherwise be storing urine
-
Voiding symptoms
- Occur usually due to bladder outlet obstruction, making it more difficult to pass urine
-
Post-micturition symptoms
- Occurs after voiding
Give 4 examples of different storage symptoms you may see
- Increased urinary frequency
- Nocturia
- Increased urgency to urinate
- Urge incontinence
List 5 examples of voiding symptoms you might see.
- Hesitancy
- Intermittent / poor flow (<10mL/s)
- Straining
- Incomplete emptying
- Terminal dribbling
Give 2 examples of post-micturition symptoms.
- Terminal dribble
- Feeling of incomplete emptying
What specific things do you need to clarify from the patient when taking a history of LUTS?
- The exact nature of lower urinary tract symptoms present
- Ask about all the different symptoms.
- Establishing whether symptoms are mostly voiding / storage / post-micturition
- Ask about other associated symptoms
- Visible haematuria
- Suprapubic discomfort
- Colicky pain
- Medication Hx
* Some medications are known to cause LUTS (e.g. anticholinergics, antihistamines & bronchodilators)
What symptoms does overactive bladder typically present with?
- Storage symptoms
- Urgency
- Increased frequency
- Nocturia
- Urge incontinence
- Can also present with other types of incontincence (e.g. stress, mixed, functional)
What is bladder outlet obstruction (BOO)? & Who most commonly suffers from it?
When there is some impediment to the normal smooth, complete and rapid voiding of the bladder (encompassed within the term LUTS)
- Most common in older men, often due to prostate problems
What symptoms do patients w/ bladder outlet obstruction typically present with?
- Pain when urinating (dysuria)
- Increase frequency
- Voiding & Post-micturition symptoms
- Incomplete empyting
- Poor stream
- Hesitancy
How would you like to examine a patient w/ LUTS?
- DRE +/- examination of the external genitalia
- Depending on presentation
What is the International Prostate Symptom Score?
A useful tool for assessing and monitoring the impact of LUTS on quality of life in men
- Both initially and throughout any treatment course
What initial investigations are useful for a patient with LUTS?
- Urinalysis & culture
- To look for evidence of UTI, haematuria or glycosuria
- If infection likely, culture urine
- Routine bloods
- FBC = anaemia/infection
- U&Es = Kidney function
- PSA (w/ likely prostate pathology)
- After appropriate counselling
- Post-void bladder scanning and flow rate
* To help distinguish between causes of LUTS & to quantify the severity of the condition in those presenting with voiding symptoms. A urinary frequency and volume chart is often useful in highlighting patterns of behaviour which may be contributing to symptoms.
What specialist investigations might you want for a patient with LUTS?
- Urodynamic studies
* To assess flow rate, detrusor pressure, and storage capacity if indicated - Cystoscopy (Gold standard investigation for assessing the lower urinary tract)
* If clinically indicated, such as a history of recurrent infection or the presence of haematuria. - Upper urinary tract imaging (USS / CT)
* If there is a history of chronic retention, recurrent infection, or the presence of haematuria.
How would you describe urodynamic studies to a patient?
Different types of tests that look at how well your bladder, urethra (the tube that passes urine from your bladder) & sphincters are functioning /storing and releasing urine.
We usually use them to show us the bladder’s ability to hold urine & empty it steadily and completely. But sometimes we use them to show us whether the bladder is having involuntary contractions that cause urine leakage.
What is uroflowmetry?
A non-invasive test (urodynamic study) that measures:
- Volume of urine released from the body
- Speed at which it is released
- How long the release takes.
To assess bladder and sphincter function
How would you explain uroflowmetry to a patient?
You’ll need to urinate into a funnel-shaped device. As you do so, an electric device connected to the funnel measures the:
- Speed of flow
- Quantity of urine prod
- Length of time it takes to empty bladder completely
It draws this information on a chart. Normally, the initial urine stream begins slowly, speeds up, and then finally slows down again. Any differences from the norm will be recorded and used to form your diagnosis.
What is the conservative management of patients with mostly storage symptoms?
- Regulating fluid intake
- Timing and volume of drinks consumed
- Reducing caffeinated & alcoholic beverages in evenings
- Techniques to assist voiding
- Urethral milking techniques
- Manually emptying the bulbar urethra of residual urine
- Double voiding
- Passing urine and then waiting shortly before passing urine again
- Pelvic floor exercises
For patients with stress incontinence or post-micturition dribble.
- To strengthen the pelvic floor
4. Bladder training techniques
For patients with overactive bladder
- To increase the duration between the urge to void and micturition
How is LUTS managed pharmalogically, when conservative methods are insufficienct / inappropriate?
For overactive bladder:
-
Anticholinergics (e.g. oxybutynin, tolterodine)
- Helps to relax bladder muscle by opposing parasympathetic cholinergic control of contraction
-
Mirabegron
- A β3 adrenergic agonist
For BPH
- Alpha blockers (e.g. alfuzosin, tamsulosin)
- 5α-reductase inhibitors (e.g. finasteride)
Both work to reduce prostate size by relaxing prostatic muscle
For nocturia:
- Mid-afternoon loop diuretics (e.g. furosemide, bumetanide)
- Desmopressin
Both treatments are unlicensed
What are the complications of untreated LUTS?
- Infection
- Formation of renal & bladder calculi
- Due to stagnation of urine.
Chronic obstruction may lead to :
- Bladder wall muscle hypertrophy
- Bladder distention
- Overflow incontinence.
- Renal failure
- Bilateral hydronephrosis.
- Acute urinary retention (in progressive BPH)
What is nocturnal polyuria?
Excessive urine production overnight
What is the aetiology & management of nocturnal polyuria?
Aetiology
- Associated with
- Sleep apnoea
- Swollen ankles
- HF
Management
Fluid restriction
+/- diuretics & vasopressin / oral desmopressin
What are some causes of bladder outlet obstruction?
- Urethral polyps / strictures
- BPH
- Bladder neck stenosis
- Prostatic carcinoma
- Faecal impaction
- Pelvic tumour
What is the management of BOO?
- Catheter insertion
* To relieve he blockage and drain bladder - Drugs to treat causes
* e.g alpha blockers / 5-alpha-reductase inhibitors for BPH - Surgery
* TURP = Transurethral resection of Prostate
