LUTS Flashcards
What is urinary incontinence?
- 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
What are the common types of urinary incontinence in women?
- Stress
- Urgency
- Mixed (stress + urge)
- Chronic retention/overflow
What is stress incontinence?
- 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
Which investigations for stress incontinence?
- Exam → incontinence occurs when pt coughs; there may be a cystocele
- Bladder diary → records frequency + volumes
- Urodynamics → shows flow of urine when pt coughs
What is the management for stress incontinence?
- Conservative → pelvic floor strengthening exercises are required for at least 6 months, plus weight loss + fluid advice
- Surgery → vaginal slings or Burch Colposuspension
What is urge incontinence?
- 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
What is the management of urge incontinence?
- 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
What is overflow incontinence?
- 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
What is the treatment for overflow incontinence?
- Relieving the obstruction
- Eg. TURP
- Or intermittent self-catheterisation
LUTS can be divided into storage, voiding and post-micturition symptoms.
What are storage symptoms?
- Frequency
- Urgency
- Nocturia
- Incontinence
What are the voiding symptoms?
- Slow stream
- Splitting or spraying
- Intermittency
- Hesitancy
- Straining
- Terminal dribble
What are post-micturition symptoms?
- Post-mic dribble
- Feeling of incomplete emptying
For male LUTS, what is involved in a basic evaluation?
- History + assessment of symptoms and bother
- Digital rectal examination
- Urinanalysis
- Serum PSA
- Frequency - vol chart (voiding diary)
What is involved in a specialised evaluation for LUTS?
- Detailed quantification of symptoms by standardised questionnaires
- Flow rate recording
- Residual urine
- Pressure flow studies
What is acute urinary retention?
- 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
What is the management of acute urinary retention?
- 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
What is obstructive uropathy?
- 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
For obstructive uropathy, ask for an urgent renal US.
What should be considered?
- 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