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Urinary Systems > Urinary Tract Obstruction > Flashcards

Urinary Tract Obstruction Flashcards

1
Q

What is the definition of acute urinary retention?

A

Painful inability to void with a palpable and percussible bladder

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2
Q

How much do residuals vary in acute urinary retention?

A

500ml to >1L depending on time lag in seeking medical attention

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3
Q

What is the main risk factor for acute urinary retention?

A

BPO

Can also occur independently of BPO
-(e.g. UTI, urethral stricture, alcohol excess, post-op causes, acute surgical or medical problems)

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4
Q

For people with BPO when can acute urinary retention occur?

A

Spontaneously (i.e. natural progression of BPO)

Triggered by an unrelated event (e.g. constipation, alcohol excess, post-op causes, urological procedure)

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5
Q

What is the immediate treatment of acute urinary retention?

A

Catheterisation (either urethral or suprapubic)

Will feel better straight away

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6
Q

What are the complications of catheterisation in acute urinary retention?

A

UTI

Post decompression haematuria

Pathological diuresis

Renal failure

Electrolyte abnormalites

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7
Q

After catheterisation in acute urinary retention what is the next step?

A

Treat underlying trigger if present.

If no renal failure, start alpha blocker immediately and remove catheter in 2 days (60% will void successfully);
-If fail to void, recatheterise and organise TURP (after 6 weeks)

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8
Q

What is the definition of chronic urinary retention?

A

Painless, palpable and percussible bladder after voiding

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9
Q

How much do residuals vary in chronic urinary retention?

A

patients often able to void but with residuals ranging from 400ml to >2L depending on stage of condition (i.e. wide spectrum)

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10
Q

What are the main aetiological factors in chronic urinary retention?

A

Detrusor underactivity which can be primary (i.e. primary bladder failure) or secondary (i.e. due to longstanding BOO, such as BPO or urethral stricture)

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11
Q

How does chronic urinary retention present?

A

LUTS

Or complications:
-UTI, bladder stones, overflow incontinence, post-renal or obstructuve renal failure) or incidental finding

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12
Q

When does overflow incontinence and renal failure occur in chronic urinary retention?

A

Severe end of spectrum, when bladder capacity is reached and bladder pressure is in excess of 25cm water

(i.e. decompensated chronic urinary retention or acute-on-chronic urinary retention or high pressure chronic urinary retention)

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13
Q

When should you treat in chronic urinary retention?

A

Asymptomatic patiens with low residuals so not necessarily need treatment

Patients with symptoms or complications need treatment (but no role for medical therapy!)

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14
Q

What is the immediate treatment in chronic urinary retention?

A

Catheterisation (either urethral or suprepubic initially, followed by CISC if appropriate)

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15
Q

What is CISC?

A

Clean Intermittant Self Catheterisation

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16
Q

What are the complications of catheterisation in chronic urinary retention?

A

UTI

Post decompression haematuria

Pathological diuresis

Electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis),

Persistant renal dysfunction due to acute tubular necrosis

17
Q

What are the features of pathological diuresis?

A 
Urine output >200ml/hr
\+
Postural Hypertension (systolic differential >20mmHg between lying and standing)
\+
Weight loss
\+
Electrolyte abnormalities
18
Q

How do you manage someone after immediate treatment in chronic urinary retention?

A

Manage with IV fluids (total input = 90% of output) and monitor closely; liase with renal team
- This is to prevent post-obstructive diuresis

Subsequent treatment is with either long term urethral or suprapubic catheter, CISC or TURP

19
Q

What is Post obstructive diuresis (pathological diuresis)?

A

Postobstructive diuresis is a polyuric response initiated by the kidneys after the relief of a substantial bladder outlet obstruction. In severe cases this condition can become pathologic, resulting in dehydration, electrolyte imbalances, and death if not adequately treated

20
Q

Chronic urinary retention is further divided into high and low pressure CUR.

What is the difference?

A

The presence or absence of intrinsic detrusor pressure is what differentiates them.

High-pressure CUR results from an obstruction with the presence of detrusor muscle activity, while low-pressure CUR involves detrusor failure with low intravesical pressure.

This distinction is important, as high detrusor pressure can lead to upper urinary tract damage and present with new-onset hypertension, peripheral edema, or renal dysfunction.

21
Q

How does TURP success in chronic urinary retention compare to acute urinary retention?

A

Less successful outcome in chronic than fro acute retention; however, patients with high pressure chronic retention have better outcome with TURP than with low pressure chronic retention.

22
Q

What are the two types of urinary tract obstruction?

A

Upper tract
- i.e. supra-vesical

Lower tract
- i.e. bladder outflow obstruction

23
Q

Where can upper urinary tract obstruction occur?

A

Pelvi-Ureteric Junction

Ureter

Vesico-Ureteric Junction

24
Q

Where can lower urinary tract obstruction occur?

A 
Bladder neck
Prostate
Urethra
Urethral meatus
Foreskin (e.g. phimosis)
25
Q

What kinds of things may cause upper tract obstruction?

A

PUJ obstruction (physiological or crossing vessel)

Stone or blood clot

Ureteric tumour (TCC)

Lymph nodes or abdominal mass

bladder tumour

26
Q

What are the symptoms and signs of upper tract obstruction?

A

Symptoms:

  • Pain
  • Frank haematuria
  • Symptoms of complications

Signs

  • Palpable mass
  • Microscopic haematuria
  • Signs of complications
27
Q

What are the complications of upper tract obstruction?

A

Infection and sepsis

Renal failure

28
Q

When do you really need to worry about upper tract obstruction and act fast?

A

Infection
Acute retention
Renal failure

29
Q

What is involved in resiscitation in upper tract obstruction?

A

ABCs

IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring

IV fluids, broad spectrum antibiotics (if appropriate)

Analgesics

HDU care +/- renal replacement therapy if appropriate

30
Q

What is involved in the emergency treatment of upper tract obstruction?

A

For unremitting pain or complications

-Percutaneous nephrostomy insertion

OR

-Retrograde stent insertion

(This buys you time for definitive treatment)

31
Q

What is percutaneous nephrostomy insertion?

A

Percutaneous nephrostomy is an interventional radiology/surgical procedure in which the renal pelvis is punctured whilst using imaging as guidance.

A nephrostomy tube may then be placed to allow drainage.

32
Q

What is a retrograde stent insertion?

A

A ureteric stent
is a thin plastic tube placed in your ureter
to allow urine to drain freely from your kidney
to the bladder.

Wire up ureter into bladder to feed tube

33
Q

What is the definitive treatment of obstruction in Upper tract obstruction?

A

Treat underlying cause

e. g. stone
- Uteroscopy and laser lithotripsy +/- basketing or ESWL

e. g. ureteric tumour
- Radical nephro-ureterectomy

e. g. PUJ obstruction
- laparoscopic pyeloplasty

34
Q

How does lower tract obstruction present?

A

LUTS
-Including urinary incontinence

Acute or chronic urinary retention

Recurrent UTI and sepsis

Frank haematuria

Formation of bladder stones

Renal failure

35
Q

What is involved in resuscitation in lower tract obstrcution?

A

ABCs

IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring

IV fluids, broad spectrum antibiotics (if appropriate)

Analgesics

HDU care +/- renal replacement therapy if appropriate

36
Q

What investigations can you carry out in upper tract obstruction?

A

USS renal tract

CT

37
Q

What investigations can you carry out in lower tract obstruction?

A

Bladder scan

USS renal tract

38
Q

What is the emergency treatment of obstrcution in lower tract obstruction?

A

For unremitting pain or complications

-Urethral catheterisation

OR

-Suprapubic catheterisation

39
Q

What is the definitive treatment of lower tract obstruction?

A

Treat underlying cause

e. g. BPE
- TURP

e. g. Urethral stricture
- Optical urethrotomy

e. g. Meatal stensosis
- Meatal dilatation

e. g. Phimosis
- Circumcision

Urinary Systems (26 decks)

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