Urinary retention

Question 1

How can you pick up chorda equina syndrome from just acute bladder symptoms?

Answer 1

Feel for the reduced anal tone. Incontinence.

Symptoms are only around pelvis and perineum.

all normal LL & UL.

Question 2

What are the (3) reasons why indewelling catheter may not drain?

Answer 2

○ Renal failure/no urine (e.g. ovarian cyst)
○ Blocked catheter
○ Wrong hole or not fully in the bladder

Question 3

Does cystitis cause fever?

Answer 3

No

Question 4

What (3) conditions does urinary symptoms + fever indicate?

Answer 4

1. prostatitis
2. orchitis (inflammation of testes)
3. pyelonephritis

Question 5

Can urinary symptoms lead to hydronephrosis & renal failure?

Answer 5

Yes (due to back pressure)

Question 6

Describe acute urinary retention

• its possible causes
• Rx

Answer 6

· = sudden & PAINFUL inability to pass urine
· Acute urinary symptoms CAN occur idiopathically without any precipitating factors.
· Bleeding (clot retention)
· Fix by putting in a catheter -> retention goes away with pain = acute urinary retention. If not, something else.
· If the catheter does not go in: stricture etc. Mx with suprapubic aspirate.

Question 7

Describe chronic urinary retention

• its possible causes
• Rx

Answer 7

· Gradual & PAINLESS inability to pass urine
· Neurogenic
· Central
· Peripheral (DM)
· Longterm voiding dysfunction with decompensated detrusor
· Aging

Question 8

What are the (3) causes of obstructive LUTS?

Answer 8

1. BPH
2. Ca prostate
3. Stricture (scarring of urethra due to instrumentation, radiotherapy, STI, pelvic fracture, perineum trauma)

Question 9

What are the causes of irritative LUTS?

Answer 9

· Secondary to obstruction
· UTI
· Ca bladder (irritable, old age, smokers) -> cystoscopy
· Massive ovarian cyst
· Ca Cervix
· Bladder Stones (due to obstructions)
· Diabetes
· Neurological disorders (spinal injury, MS; can first present with bladder symptoms, strokes, parkinson's) 
· TB

Question 10

What are precipitants of LUTS?

Answer 10

○ Medication (anticholinergic/sympathicomimetic)
○ UTI
○ Diuresis (alcohol)
○ Postoperative (pain, anesthetic, analgesics, loss of mobility)

Question 11

What are (3) conditions related to BPH?

Answer 11

1. Urethral stricture
2. Pelvic trauma
3. Cancer

Question 12

(4) Px of obstructive LUTS

Answer 12

· Poor flow
· Hesitancy
· Intermittency
· Terminal dribbling

Question 13

(4) Px of irritative LUTS

Answer 13

· Frequency
· Urgency
· Nocturia
· Incontinence

Question 14

How can obstructive lead to irritative symptoms?

Answer 14

○ as urine does not empty properly & lead to bacterial infection.
○ Thickening of the bladder wall (irritable) -> over activity of the bladder like AF (compare bladder to the heart with cardiomyopathy etc)

Question 15

Ix of LUTS

Answer 15

• MSU
• U/E & Cr
• Bladder diary
• Voiding flow rate
• US of bladder, prostate, kidneys: residual urine & hydronephrosis
• Renal function test
• ?PSA marker for prostate cancer. It is a screening test.

Question 16

What would you check on examination for LUTS

Answer 16

• Abdomen: palpable/percussible bladder?
• Genitalia: phimosis/balanitis/meatal stenosis/epididymitis (prostatitis -> acute urinary symptoms, fever etc)
• DRE: CaP? Rectal mass? (prostate size)?
○ Size of the prostate
○ Benign feeling gland
○ Look for pelvic mass
○ Texture of the glands
○ Faecal impaction: big faeces in urinary retention.
○ Anal tone: affected by neurological defect.
○ DRE for BPH however size does not give too much information for the Dx of underlying cause. Hard prostate (cancer). Only advanced cancers cause symptoms.
• Residual urine
• Focused neurological

Question 17

What drugs can cause polydipsia?

Answer 17

diabetes, lithium management for bipolar disorder

Question 18

How can you Rx urinary retention?

Answer 18

• Observe
• Establish drainage: indwelling urethral catheter, intermittent self catheterisation, suprapubic catheter

• Treat with medical treatment
○ Alpha blockers (for mild symptoms). Works acutely.
○ 5-alpha reductase inhibitors. Takes 6 months to work & only works in large prostate with PSA as a guideline. It can prevent and reduce the prevalence of cancer but if you already have cancer, it may cause high grade cancer.
○ Combination
• Treat with surgical treatment
○ TURP: Transurethral resection of prostate 95% satisfaction rates
○ BNI: bladder neck incisions for smaller prostates.

Open prostatectomy: Millen’s prostectomy