Urinary Obstruction and Altered Voiding Flashcards
What are the two categories of lower urinary tract symptoms and what occurs with them?
- Storage (incontinence): Frequency, urgency, nocturia.
- Voiding (obstruction): Weak stream, intermittency, straining, emptying incomplete
what are the 5 types of incontinence and briefly describe them.
- Stress (leakage during periods of abdominal pressure)
- Urge (leakage which follows an irresistible urge to pass urine)
- Mixed (combination of stress and urge)
- Overflow (the inability to empty the bladder with resulting overflow of urine)
- Functional (consequence of something not involving lower urinary tract, e.g. psychological, cognitive or physical impairment)
What are the 4 major types of renal stones
- Calcium-based
- Struvite Stones - triple phosphate stones.
- Uric Acid Stones
- Cystine stones
What are key presenting symptoms for kidney stones?
Loin pain
Ureteric colic
blood in urine
dysuria
what are common risk factors and causes of urinary tract stone formation
Age and gender: higher risk in men and higher risk aged 40-60.
Diet: excessive dietary intake of oxalate (calcium stones), urate, sodium and animal protein (uric acid stones) increase risk
Ethnicity: more prevalent in caucasians
Chronic dehydration
Obesity
Family history: Cystine stones - cystinuria is a genetic condition and causes recurrent stone formation in younger people.
List the locations where urinary tract obstructions are likely to form and the complication they can cause
- Pelvic-ureteric junction (PUJ)
- Pelvic Brim - where the ureter passes over the external iliac artery at the pelvic brim and into the pelvic cavity.
- vesicoureteric junction (VUJ)
Can prevent urine drainage which causes a back-up into the kidney = hydronephrosis
Why is ureteric pain felt in the loin/groin region
visceral afferent fibres from the ureter travel to the CNS alongside sympathetic nerves. The sympathetic nerves for the ureter arise from T12-L1/2. Therefore visceral pain from the ureter is perceived in T12-L1/2 dermatomes. This pattern is described as lion to groin - T12 dermatome = loin, L1/2 = groin.
Briefly outline the investigation, examination and management of a patient with urinary obstruction (non prostate related)
Investigation:
1. Check for UTI:
- urine analysis = leukocytes, nitrites and send a sample for microscopy and culture.
- Check bloods for signs of infection e.g. raised WBC count and CRP
2. Check renal function i.e. measure creatine levels
3. Imaging - radiographs/ultrasound/non-contrast CT
Examination:
Palpate kidneys in renal angle (medial border = lateral aspect of erector spinae muscles, superior border = inferior border of the 12th rib).
Look for any guarding/pain on palpation.
Management:
1. Conservative:
- <5mm calculi may pass without any active manegement
- Dietary advise: e.g. drink more water, avoid oxalate containing foods e.g. tea/coffee/certain fruits/vegs/nut
2. Medical:
- Analgesia e.g. paracetamol/NSAIDs
- Medical Expulsive therapy <– drugs that can relax the smooth muscle in the ureter such as alpha blockers <- TAMSULOSIN
3. Surgical:
- Ureteric stent to relieve the obstruction
- Ureteroscopy - stone removal, stone fragmentation via laser.
- Extracorporeal shock wave lithotripsy - for larger stones in the proximal ureter/renal pelvis
- Percutaneous nephrolithotomy - laparoscopic surgery to remove larger stones in the proximal ureter/renal pelvis
What is stress incontinence? List some causes of stress incontinence and the management of it
Leakage of urine during periods of abdominal pressure e.g. coughing, sneezing, lifting or straining due to the pressure inside the bladder exceeding the strength of the urethra to stay closed.
Causes/risk factors:
Damage during childbirth
Obesity
Ureteric stricture
loss of hormone support due to:
1. Menopause
2. Hysterectomy
3. Increasing age
Management of stress incontinence:
1. Conservative:
- weight loss
- pelvic floor physiotherapy
2. Medical
- oestrogen therapy
3. Surgical
- peri-urtheral injections of bulking agent into the wall of the urethra
- colposuspension - stitches to pull up the vaginal walls on either side of the urethra to support it
- sling surgery to support the urethra
- artificial urinary sphincter - implant controllable valve mechanism around the urethra or bladder neck
What is urge incontinence? List some causes of urge incontinence and the management of it
The problem of sudden detrusor contraction with uncontrolled loss of urine.
idiopathic detrusor instability
UTIs
Obstructive uropathy
diabetes
neurological disease
Management:
1. conservative
Lifestyle modifications: caffeine reduction, bladder training, pelvic floor exercises
2. Medical
Anti-cholinergic medications e.g. OXYBUTININ <– blocks acetylchoine signalling by inhibiting muscurinic receptors (M2/M3) thus reducing detrusor responsiveness/activity. (Ach causes the detrusor muscles to contract = emptying bladder)
3. Surgical
- Botox injections
- Sacral neurmodulation
- Augmentation cystoplasy
What is Benign prostatic hyperplasia? Briefly outline the cause, the symptoms and the management of BPH
Enlargement of prostate due to the proliferation of stromal and glandular elements in the inner transitional zone.
the enzyme 5alpha-reductase (type II) converts circulating testosterone into dihydrotestosterone (DHT) in the prostate. DHT binds to the nuclear androgen receptors to regulate gene expression for growth and survival of prostatic epithelium and stromal cells. <– BPH this is upregulated.
Symptoms:
-Frequency
-Urgency
-Nocturia
-Weak Stream
-Intermittency
-Straining
-Emptying incomplete
Management:
1. Conservative - watch and wait
2. Medical -
2a. ALPHA-BLOCKERS e.g. TAMSULOSIN <– blocks the alpha1-adrenergic receptor which prevents its stimulation from noradrenaline from sympathetic neurone which causes the smooth muscle in the bladder neck, urethra and prostate to relax.
2b. 5-ALPHAREDUCTASE INHIBITORS e.g. FINASTERIDE <– inhibits testosterone metabolism therefore reducing prostate size.
3. Surgical
Transurethral resection of the prostate has over 90% success rate.
