LUTS

Question 1

What is urinary incontinence?

Answer 1

• Involuntary loss of urine
• A symptom, not a diagnosis
• Bladder wall is formed from detrusor muscle (smooth) + is compliant, stretching to allow urine to fill the bladder

Question 2

What are the common types of urinary incontinence in women?

Answer 2

• Stress
• Urgency
• Mixed (stress + urge)
• Chronic retention/overflow

Question 3

What is stress incontinence?

Answer 3

• Involuntary loss of urine when the pressure inside the bladder is greater than the urethral closing pressure
• Sudden increase in abdo pressure (sneezing, coughing) raises the bladder pressure
• Causes a small amount of urine to be lost
• Common in middle-aged multiparous women and is caused by pelvic floor weakness

Question 4

Which investigations for stress incontinence?

Answer 4

• Exam → incontinence occurs when pt coughs; there may be a cystocele
• Bladder diary → records frequency + volumes
• Urodynamics → shows flow of urine when pt coughs

Question 5

What is the management for stress incontinence?

Answer 5

• Conservative → pelvic floor strengthening exercises are required for at least 6 months, plus weight loss + fluid advice
• Surgery → vaginal slings or Burch Colposuspension

Question 6

What is urge incontinence?

Answer 6

• Is involuntary bladder contractions during the filling phase
• The underlying abnormality is an overactive detrusor muscle, usually idiopathic
• Sudden urge to pass urine, which often results in incontinence
• Common in middle-aged women
• Urodynamics performed to confirm diagnosis, showing regular contractions of the detrusor while the bladder is filing

Question 7

What is the management of urge incontinence?

Answer 7

• Conservative → bladder retraining attempts to teach bladder to hold urine, thus reducing frequency and urgency
• Medical → mainstay of treatment with anti-cholinergic medications (eg. oxybutynin, tolterodine) that prevent detrusor overactivity; SE: blurred vision, dry mouth, constipation
• Surgery → Botulinum toxin A has been used v successfully; injected into bladder via cystoscopy

Question 8

What is overflow incontinence?

Answer 8

• When bladder cannot fully empty, there is ‘overflow’ of urine, leading to frequency of small amounts of urine + constant dribbling; this often occurs during the day + night
• Cystometry confirms diagnosis, showing an overfull bladder with weak contraction + weak detrusor activity

Question 9

What is the treatment for overflow incontinence?

Answer 9

• Relieving the obstruction
• Eg. TURP
• Or intermittent self-catheterisation

Question 10

LUTS can be divided into storage, voiding and post-micturition symptoms.

What are storage symptoms?

Answer 10

• Frequency
• Urgency
• Nocturia
• Incontinence

Question 11

What are the voiding symptoms?

Answer 11

• Slow stream
• Splitting or spraying
• Intermittency
• Hesitancy
• Straining
• Terminal dribble

Question 12

What are post-micturition symptoms?

Answer 12

• Post-mic dribble
• Feeling of incomplete emptying

Question 13

For male LUTS, what is involved in a basic evaluation?

Answer 13

• History + assessment of symptoms and bother
• Digital rectal examination
• Urinanalysis
• Serum PSA
• Frequency - vol chart (voiding diary)

Question 14

What is involved in a specialised evaluation for LUTS?

Answer 14

• Detailed quantification of symptoms by standardised questionnaires
• Flow rate recording
• Residual urine
• Pressure flow studies

Question 15

What is acute urinary retention?

Answer 15

• Sudden inability to pass urine and is a urological emergency
• Common in older men
• May be acute presentation of BPH
• May follow any operation (particularly pelvic surgery) or anaesthetic (spinal)
• Bladder is palpable + dull to percussion, may be enlarged to umbilicus

Question 16

What is the management of acute urinary retention?

Answer 16

• Patient requires urgent urinary catheterisation
• Attempted first by urethral then suprapubic if fail
• Chronic retention? → controlled emptying or risk renal failure
• PR after decompression to check whether prostate enlargement is benign or malignant

Question 17

What is obstructive uropathy?

Answer 17

• Chronic urinary retention
• In chronic urinary retention, an episode of acute retention may go unnoticed for days and, because of their background symptoms, may only present when overflow incontinence becomes a nuisance
• After diagnosing acute on chronic retention and placing a catheter, the bladder residual can be as much as 1.5L or urine

Question 18

For obstructive uropathy, ask for an urgent renal US.

What should be considered?

Answer 18

• Hyperkalaemia
• Metabolic acidosis
• Post-obstructive diuresis → in the acute phase after relief of the obstruction, the kidney produce a lot of urine. It is vital to provide resuscitation fluids and then match input with output
• Sodium and bicarbonate-losing nephropathy → As the kidneys undergoes diuresis, Na and bicarbonate are lost in the urine in large quantities. Replace ‘in for out’ with isotonic 1.26% sodium bicarbonate solution