LUTS in men and women Flashcards
Common storage symptoms in men with LUTS
Frequency
Nocturia
Urgency
Urge incontinence
Common voiding symptoms in men with LUTS
Hesitancy
Poor flow
Straining
Intermittancy
Common post-micturition urinary symptoms in men with LUTS
Sensation of incomplete emptying
Post micturition dribble
Common causes of male LUTS
Bladder outflow obstruction
(usually due to BPH or urethral strictures)
Overactive bladder (can be primary or secondary to obstruction/carcinoma in-situ/neuro/radiation/infection)
Urinary tract infection
(prevent with dysuria, positive dip)
Bladder stones
symptoms that characterise bladder outflow obstruction (BOO)
Hesitancy Poor flow Intermittent flow Post-micturition dribble Incomplete emptying
symptoms that characterise overactive bladder syndrome (OAB)
- in men it accompanies obstruction
- URGENCY with/without incontinence
- often accompanied by frequency and nocturia
describe flow-rate testing (uroflowmetry)
- You need a voided vol of 150mls minimum
If Qmax>15mls/sec = 10-30% chance of obstruction
If Qmax 10-15mls/sec = 60% chance of obstruction
If Qmax <10mls/sec = 90% chance of obstruction
Filling:
- should be slow gentle rise in pressure
- phasic contractions = detrusor overactivity and urgency (feature of OAB)
- patient asked to cough to look for stress incontinence
Voiding:
- high pressure + low flow = obstruction
- low pressure + low flow = detrusor failure
What are the medical (drug) treatments for BOO
Medical =
alpha blockers
(tamsulosin, alfuzosin)
- relax prostatic/bladder neck smooth muscle
- SEs = only symptomatic control, retrograde ejaculation, postural hypotension
5-alpha reductase inhibitors (finasteride/ dutasteride)
- reduce conversion of testosterone to DHT, reduces prostatic volume
- only works when BPH is the problem (PSA>1.4, prostate>30g)
- reduces progression of disease
- SEs = erectile dysfunction, decreased libido, rash
anticholinergics (if OAB symptoms too)
What are the conservative and surgical treatments for BOO.
When is surgery indicated?
Conservative = advise on fluid intake, caffeine, etc
Surgical =
- TURP or laser prostate surgery
- Open retropubic (Millin’s) prostatectomy
- Needed in failure of medical therapy or development of complications eg. chronic retention, bladder stones, persistent haematuria
Investigations you would do for LUTS
- History
- Post-void bladder scanning and flow rate
- Urinary freq and vol chart
- Urinalysis (haematuria in bladder stones, glycosuria in DM, etc)
- Urine culture to investigate infection
- Routine bloods (FBC, U&Es)
- Urodynamic studies
- Cystoscopy to investigate lower urinary tract
- US or CT scanning for upper urinary tract imaging to investigate retention etc.
Risks of TURP?
TURP syndrome
- hypoosmolar irrigation for standard TURP is glycine (as it acts as electrical insulator)
- absorption through exposed venous beds during a long resection can lead to dilutional hyponatraemia = fits, confusion, visual symptoms, coma
Avoid this with bipolar TURP and laser TURP
How do you you distinguish between Overactive Bladder/Urge-Incontinence from Stress incontinence
Stress
- provoked by coughing/sneezing/laughing/standing
- leaks a SMALL amount
- no sensation of urge
Urge
- preceded by sensation of urgency
- can also be provoked by coughing
- also provoked by running water, cold, “latch-key”
- leak LARGE amounts
What are the common causes of incontinence in women?
- pregnancy or vaginal delivery
(stretching and weakening of muscles + damage to pudendal and pelvic nerves) - overweight
- old age
- constipation
- dementia
- strenuous activities eg. weight lifting
(increased stress on pelvic support structures)
What are the conservative and surgical treatment options for stress incontinence
Conservative
- weight loss
- pelvic floor exercises
Surgical - examine for prolapse and treat if present - Tension-Free Vaginal Tape and Transobturator Tape are the gold standard (risk of erosion) - Autologous slings - Colposuspension - Artificial sphincter mostly in men - Urinary diversion
Which neuro conditions can commonly impact on bladder/sphincter function?
Spina bifida
- causes neurogenic OAB and stress incont
- risk of hydronephrosis/ renal failure
Spinal Cord Injury
- causes neurogenic OAB or areflexic bladder
- can cause overactive sphincter (Detrusor-sphincter dyssynergia) or underactive sphincter (Neurogenic Stress Incontinence)
Diabetes, MS, Parkinsons all have low risk of renal failure
