Urinary Symptoms

Question 1

What is urinary frequency?

Answer 1

The need to urinate more often than usual

Question 2

What is polyuria?

Answer 2

Abnormal production and passage of large amount of urine.
>2.5L daily

Question 3

What is nocturia?

Answer 3

The need to wake up at night to urinate

Question 4

What is hesitancy?

Answer 4

Difficulty starting to urinate, challenge starting a stream and keeping it flowing

Question 5

What is poor flow?

Answer 5

Weak stream of urine when passing

Question 6

What is terminal dribbling ?

Answer 6

Continue to leak urine after micturition has ceased

Question 7

How can LUTS be divided?

Answer 7

Storage symptoms

Voiding symptoms

Post-micturition symptoms

Question 8

What is stress incontinence?

Answer 8

involuntary leakage on effort or exertion, or on sneezing or coughing

Question 9

What is mixed incontinence?

Answer 9

both stress and urgency incontinence; involuntary leakage is associated with both urgency and physical stress

Question 10

What is urgency incontinence?

Answer 10

involuntary leakage accompanied by, or immediately preceded by, a sudden compelling desire to pass urine

Question 11

What is overflow incontinence?

Answer 11

detrusor underactivity or bladder outlet obstruction results in urinary retention and leakage of urine. There may be straining to urinate or the person may feel the bladder has been incompletely emptied

Question 12

What can be used to monitor urinary symptoms?

Answer 12

Frequency volume charts
Voiding diaries

Question 13

What examination should be done for someone presenting with urinary incontinence?

Answer 13

Perform a general examination, looking for features such as weight, abnormalities of gait, and indicators of neurological disease.

Examine the abdomen for a palpable bladder or a mass.

Perform a pelvic examination - get them to cough and assess tone

Question 14

What should you ask when taking history of incontinence?

Answer 14

If incontinence occurs when coughing, sneezing, or on effort or exertion (likely to be stress urinary incontinence), or

If there is sudden urgency, and if they have frequency and nocturia (likely to be urgency incontinence associated with overactive bladder syndrome).

If incontinence occurs about equally with physical activity and urgency (suggests mixed incontinence).

If incontinence occurs without physical activity or a sense of urgency (suggests a cause other than stress or urgency incontinence)

Question 15

If incontinence isn’t characterised by stress or urgency what else should you ask when taking about?

Answer 15

Voiding difficulty (for example straining to void, sensation of incomplete emptying) — may suggest chronic urinary retention (overflow incontinence).

Constant leakage of urine (may be intermittent if position dependent) — suggestive of a fistula (for example vesicovaginal).

Post-void dribbling, pain, urgency, frequency, recurrent urinary tract infection, vaginal discharge, and dyspareunia — consider a urethral diverticulum

Question 16

What are some LUTS that women may experience?

Answer 16

Burning or stinging when you pass urine.

Constant lower tummy (abdominal) ache.

Needing to pass urine often (frequency).

An urgent feeling of needing to empty your bladder (urgency).

Loss of bladder control (Incontinence).

Needing to get up to urinate several times in the night.

Feeling of needing to empty your bladder even after urinating. Or, a dribble of urine after you think you have finished.

Difficulty urinating.

A slow stream of urine

Question 17

What are some causes of LUTS in women?

Answer 17

UTI

Menopause

Urge incontinence

Stress incontinence

Diabetes mellitus

Bladder stones

Bladder cancer

Neurological conditions e.g. MS

Medication e.g. amitriptyline, diuretics, lithium

Question 18

What are some investigations done for LUTS in women?

Answer 18

A urine dipstick test for infection, sugar (glucose) and blood.

A urine test to send to the hospital to confirm the dipstick findings.

A blood test for glucose to rule out diabetes

USS of bladder

Urodynamics if required

Question 19

What advice could you give to a women struggling with LUTS?

Answer 19

-Avoid caffeine
-Vaginal lubricants for sore vagina after menopause
-Bladder training exercises
-Pelvic floor exercises
-Lose weight if overweight
-Stop smoking

Question 20

How can stress incontinence be managed?

Answer 20

Manage reversible causes or contributing factors
Reduce caffeine
Reduce fluid intake
Weight loss
Stop smoking
Pelvic floor muscle training - minimum of 8 pelvic floor muscle contractions 3x daily
Continence pads
Duloxetine

Question 21

How should urge incontinence be managed?

Answer 21

-Referral for bladder training
-Fluid intake and lifestyle measures
-Manage treatable causes of overactive bladder syndrome
-Antimuscarinics e.g. Oxybutynin

Question 22

What should you ask about in the history of a man with LUTS?

Answer 22

Ask about the type (or combination of types) of lower urinary tract symptoms

Ask about the severity of symptoms and the impact on quality of life, for example

Ask about possible underlying causes of the specific type of LUTS, including comorbidities (such as diabetes and multiple sclerosis)

Ask about sexual function (preferably using a validated symptom questionnaire, such as the International Index of Erectile Function

Ask about lifestyle habits.

Review emotional and psychological factors.

Review current medication, including herbal and over-the-counter medicines

Question 23

What examinations should be done for men with LUTS

Answer 23

Examine the abdomen for signs of a distended, tender, palpable/percussible bladder.

Examine the external genitalia to identify conditions that may cause or contribute to LUTS (for example, phimosis, meatal stenosis, or penile cancer).

Perform a digital rectal examination to assess the prostate’s symmetry, size, firmness, surface smoothness, tenderness, and midline groove.

Examine the perineum and/or lower limbs (to evaluate motor and sensory function

Question 24

What are some red flags for men with LUTS?

Answer 24

Urological cancer — may present with unexplained haematuria, lower back pain, bone pain, and weight loss. Rectal examination may show a prostate that is hard and irregular - refer for 2wk wait

Urological infection — may present with pain when urinating, pelvic pain, loin pain, fever, and abnormal urine dipstick test findings

Sciatica — may present with weakness, numbness, or tingling in the leg and can cause or aggravate LUTS

Cauda equina syndrome -bilateral neurological deficit of the legs, gait disturbance or difficulty walking, difficulty initiating micturition or impaired sensation of urinary flow, loss of sensation of rectal fullness, perianal, perineal, or genital sensory loss (saddle anaesthesia or paraesthesia), laxity of the anal sphincter, and erectile dysfunction.

Question 25

What can urinary frequency-volume charts help diagnose?

Answer 25

Frequency.

Polyuria (passing more urine than usual) — up to 3 L of urine in 24 hours is normal.

Nocturia (waking at night to urinate).

Nocturnal polyuria (passing, at night, more than 35% of the 24-hour urine production)

Question 26

What is the international prostate symptom score?

Answer 26

tool for classifying the severity of lower urinary tract symptoms (LUTS) and assessing the impact of LUTS on quality of life

The IPSS severity score is interpreted as:
Score 0: asymptomatic.
Score 1–7: mildly symptomatic.
Score 8–19: moderately symptomatic.
Score 20–35: severely symptomatic

Question 27

How should you manage a man with voiding symptoms?

Answer 27

Exclude serious underlying causes of LUTS and manage treatable causes if possible.

Offer advice on lifestyle interventions

Discuss active surveillance

Alpha blocker- alfuzosin, doxazosin, tamsulosin, or terazosin

Offer a 5-alpha reductase inhibitor (dutasteride or finasteride) to men with LUTS who have a prostate estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml and who are considered to be at high risk of progression

Question 28

How can the causes of erectile dysfunction be divided?

Answer 28

Organic causes

Psychogenic causes

Drugs

Question 29

What are some organic causes of erectile dysfunction?

Answer 29

Vasculogenic - cvd, HTN, t1/2dm, smoking, obesity, radiotherapy etc

Neurogenic- degenerative disorders (such as multiple sclerosis, Parkinson’s disease, and multiple system atrophy), stroke, spinal cord trauma or disease, or central nervous system (CNS) tumours. type 1 and 2 diabetes mellitus, chronic kidney disease, chronic liver disease, polyneuropathy, major surgery of the pelvis or retroperitoneum, or urethral surgery

Anatomical or structural — Peyronie’s disease, penile cancer, prostate cancer, congenital curvature of the penis, micropenis, hypospadias, epispadias, or phimosis

Endocrine — type 1 and type 2 diabetes mellitus, metabolic syndrome, primary or secondary hypogonadism, hyperprolactinaemia, hyper- or hypothyroidism, Cushing’s disease, panhypopituitarism and multiple endocrine disorders, or hypopituitarism following traumatic brain injury

Question 30

What are some psychogenic causes of erectile dysfunction?

Answer 30

Generalized — for example, due to lack of arousability and disorders of sexual intimacy

Situational- partner- or performance-related issues, stress, depression, anxiety, post-traumatic stress disorder, or psychosis

Question 31

What are some drugs that can lead to erectile dysfunction?

Answer 31

Antihypertensives — beta-blockers, verapamil, methyldopa, and clonidine.

Diuretics — spironolactone and thiazides.

Antidepressants — tricyclics, monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), lithium, and venlafaxine.

Antiarrhythmic drugs — digoxin and amiodarone.

Anticholinergics — pregabalin, gabapentin, and duloxetine.

Antiepileptics — carbamazepine, topiramate, gabapentin, and pregabalin.

Antipsychotics/tranquilizers — chlorpromazine, haloperidol, and phenothiazines.

Hormones and hormone-modifying drugs — anti-androgens (such as cyproterone acetate); gonadotrophin-releasing hormone agonists (such as leuprorelin, goserelin); corticosteroids; 5-alpha reductase inhibitors (such as finasteride), oestrogens, and progesterone.

Histamine (H2)-antagonists — cimetidine and ranitidine.

Cytotoxic drugs — cyclophosphamide and methotrexate.

Recreational drugs — alcohol, heroin, cocaine, cannabis, methadone, anabolic steroids, and opiates

Question 32

How should you assess someone with erectile dysfunction?

Answer 32

Ask about psychosexual factors e.g. sexual function, orientation, self belief, trauma

Ask about other medical history e.g. CVD, HTN, stroke,LUTS

Physical examination- BP, HR, bmi, waist circumference, Check for gynaecomastia, sparse body hair, and reduced muscle mass to assess for testosterone deficiency

Consider examination of the external genitalia to assess for:
Signs of hypogonadism, such as testicular atrophy and alterations in secondary sexual characteristics.
Penile foreskin conditions, such as phimosis or lichen sclerosus.
Penile structural abnormalities, including Peyronie’s disease (causes abnormal angulation of the erect penis), hypospadias, phimosis, and penile cancer
Testicular abnormalities if there are symptoms of testicular lump, swelling, or pain

DRE

Blood tests - hba1c, lipid profile, testosterone. LFTs and u&es

Question 33

How can erectile dysfunction be managed medically?

Answer 33

For men not at high cardiac risk of sexual activity, consider prescribing drug treatment with a phosphodiesterase-5 (PDE-5) inhibitor

Options include sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®), and avanafil (Spedra®)