Urinary obstruction and altered voiding

Question 1

What are the common symptoms of lower urinary tract problems? (LUTS)

Answer 1

Storage - Incontinence, urgency, frequency, nocturia
Voiding - Poor stream (weak/intermittent), hesitancy, dysuria, intermittency, double voiding, retention, straining, incomplete emptying, terminal dribbling
Post-micturition - terminal dribble and the sensation of incomplete emptying

Question 2

What are the problems associated with urinary incontinence?

Answer 2

Social/health problem
QoL impact
Skin breakdown - pressure sores

Question 3

What are the different types of incontinence?

Answer 3

Stress (poor sphincter resistance)
Urge/urgency (overactive bladder)
Mixed (stress and urge)
Overflow (chronic retention and detrusor failure)
Continuous
Childhood
Functional (psychological. cognitive or physical imp)

Question 4

If a patient was taking furosemide and they needed to urinate after taking it and maybe need to get up at night as well, what type of incontinence is this?

Answer 4

Functional incontinence

Question 5

Describe the history, examination and investigations you would perform for incontinence.

Answer 5

H: Precipitating events, duration, pad usage, bother; medical/surgical history
E: Abdomen, pelvic (genitalia), digital rectum exam
Neurologic exam, mental status & mobility
I: dipstick, microscopy, sensitivity and culture. cytology, FBC, U&Es, glucose, freq-vol chart (bladder diary), urodynamics

Question 6

What is urodynamics?

Answer 6

Study of pressure and flow during storage, transport and expulsion of urine in the (lower) urinary tract

Question 7

What is outflow cystometry?

Answer 7

Fill bladder with fluid (+/- contrast for imaging)
record pressures in bladder and rectum.
Bladder emptied and pressures recorded
Bladder – rectum = detrusor

Question 8

What are the treatment options/management plan for a patient with continuous incontinence?

Answer 8

surgical treatment of underlying anatomical disorder

catheterisation

Question 9

What are the treatment options/management plan for a patient with stress incontinence?

Answer 9

Incontinence protection
Pharmacological
Surgery

Question 10

What are the treatment options/management plan for a patient with urge incontinence?

Answer 10

Avoid stimulants
Bladder retaining
Anticholinergics: OXYBUTYNIN
Beta3 adrenergic agonists
Surgery

Question 11

What are the treatment options/management plan for a patient with urinary retention?

Answer 11

Restore bladder emptying
Intermittent self-catheterisation
Long-term catheter
α blockers: TAMSULOSIN
Surgical treatment of bladder outflow obstruction

Question 12

What is oxybutynin used to treat, what is its MoA and side effects?

Answer 12

Urge incontinence/overactive bladder
Anticholinergic - inhibits muscarinic receptors by blocking acetylcholine receptors - reduces detrusor muscle activity.
SE: Blurred vision, glaucoma, Fatigue, Tachycardia, urinary retention

Question 13

What are the differential diagnoses for urinary retention (urinary obstruction)?

Answer 13

BPH
Prostate cancer
Prostatitis
Haematuria 
Tumours
Stones
Structural

Question 14

What are the symptoms of BPH? (benign prostate hyperplasia)

Answer 14

Enlarged prostate - compresses urethra (>50)
Hesitancy
Straining/taking a long time while urinating
weak flow of urine
“stop-start” peeing
Urinate urgently/frequently, nocturia
feeling that your bladder has not emptied fully

Question 15

How can you assess the impact of BPH on a patient?

Answer 15

Calculate the international prostate symptom score (7 qs and 1 QoL q)

Question 16

What examinations/investigations can you perform to diagnose BPH?

Answer 16

International prostate symptom score
Inc prostate specific antigen (PSA)
Abdo exam
DRE
Imaging: transrectal ultrasound scan

Question 17

What are the different ways you can help a patient manage BPH? (hint: lifestyle, drugs, surgery, complications)

Answer 17

Lifestyle: less caffeine, fizzy drinks, alcohol/ do exercise
Drugs: Tamsulosin - selective alpha1 blocker
Surgery: Transurethral resection of prostate
Complications: UTI, acute urinary retention, incontinence, erectile problems

Question 18

What is tamsulosin used to treat, what is its MoA and side effects?

Answer 18

Urinary retention and BPH
Selective alpha1 blocker -> smooth muscle relaxation -> urine flow -> flow proportional to vessel diameter
SE: Dizziness, sexual dysfunction

Question 19

During a prostate, digital rectal examination, what texture can indicate cancer?

Answer 19

Hard/lumpy/irregular

Question 20

Identify the common risk factors and common causes of urinary tract stone formation.

Answer 20

Common (10%). M>F (2-4x)
Age (peak onset 20-30)
Fluid intake (dehydration facilitates stones: urine concentrated)
Family history

Question 21

Describe the common presentation signs and symptoms of urinary tract stones.

Answer 21

Loin to groin pain (ureteric colic)
Haematuria
Vomiting
Irritative voiding symptoms

Question 22

Where can kidney stones form and get stuck?

Answer 22

Pelvic ureteric junction
Pelvic brim
Vesicoureteric junction
Bladder urethra outlet

Question 23

What are the most common type of kidney stones?

Answer 23

Calcium Oxalate