Urinary Tract Obstruction Flashcards
What are the sections of the prostate?
Mcneals Zones In --> Out 1) Transition Zone (wraps around urethra 2) Central zone 3) Peripheral Zone (Where most cancers are!!!!!) 4) Ant Fibromuscular Stroma
What are Lower Urinary Tract Symptoms (LUTS)?
Split into Voiding: - Incomplete Emptying - Hesitancy - Poor Stream - Dribbling
Storage:
- Frequency
- Nocturia
- Urgency/urge incontinence
Other:
- Intermittency
- Straining
What physical signs can you detect on exam of a Bladder outflow obstruction (BOO)?
Palpable/percussible Bladder
External urethral meatus stricture
Phimosis
Mass on Digital Rectal Exam (mostly BPH)
What tests can you do for a UTO?
MSSU Flow Rate Study Post-void bladder US (looking for residual) Bloods: - PSA - U&C (only if in chronic retention) Renal tract US Cystoscopy - Good for BPE, cancer & strictures
What is BPH?
Benign Prostatic Hyperplasia.
Its a combination of fibromuscualr & glandular hyperplasia mainly affecting the transition zone, occurs in most men as they age
It can lead to BOO.
Presents with LUTS
How is BPH treated?
Medically:
- Alpha blockers (relax smooth muscle)
- 5Alpha Reductase Inhibitors (reduces prostate size by metabolising testosterone)
Surgically:
- TURP (transurethral Resection of URethra)
- OPen Prostatectomy (If >100cc)
Example of alpha blocker and 5 alpha reductase inhibitor?
Alpha Blocker - Tamsulosin
5 AR inhibitor - Dutasteride
How can a BPH be complicated?
Acute or chronic urinary retention Urinary Incontinence UTI Bladder Stone Renal Failure (due to hydronephrosis)
How can we treat a complicated BPH if they;re not fit for TURP?
- Long term urethral catheter
- CISC (clean intermittent self Catheterisation)
Whats the difference between acute & chronic urinary retention?
Acute is a painfull inability to void bladder
Chronic is painless incomplete voiding. Chronic may come with progressive LUTS, UTIs or overflow incontinence (bed wetting)
Both have a palpable and percussible bladder.
What causes Acute Urinary Retention?
Generally BPH, either as part of the natural progression or paired with some trigger like constipation or a urological procedure.
How do you treat Acute Urinary Retention?
Catheterise and start treatment for BPH
What causes Chronic Urinary Retention?
Detrusor underactivity.
Largely due to primary bladder failure or a longstanding BOO
How do you treat chronic urinary retention?
Catheterisation followed by CISC
Chronic urinary retention can be fairly ok or very dangerous, how do you tell?
High pressure CUR is incontinent, raised Cr and causes bilateral hydronephrosis
Low pressure CUR is less dangerous. Its usually dry, Cr is normal and the kidneys are ok.
Both are painless
What are the major complications when you treat a BOO/urinary retention?
Post-obstructive Diuresis
Decompression haematuria
What is post-obstructive diuresis and how do you manage it?
Massive UO >200ml/hr which can lead to life-threatening hypotension, weight loss and Electrolyte abnormalities
IV fluids resus and then a long term catheter, CISC or TURP.
What is decompression haematuria?
Shearing of the small vessles during decompression because of different compliance between different tissue layers.
Usually self-limiting
UTOs are split into upper and lower tract. What causes each?
Upper Tract:
- TCC tumours
- Stones
- Blood clots
- Scar tissue at the PUJ
- Abdominal/pelvic mass
Lower Tract:
- Mainly BPH
- Bladder Stones
- Phimosis
- Urethral Strictures
- Urethral Meatal Stenosis
How would an upper tract obstruction present?
- Pain in the flank or loin
- Haematuria (Frank or Micro)
- Palpable mass (maybe)
- Infection/sepsis, renal failure or tumour symptoms
What initial management would you use for any obstruction?
- Fluids
- Bloods, ABGs & cultures
- Analgesia
- Broad Spec Abx if signs of infection
what investigations can be used for Upper tract obstructions?
US
CT-KUB
How do you manage an upper tract obstruction?
So initial resus (fluids, analgesia, Abx etc)
Emergency bypass of the obstruction i.e. percutaneous nephrostomy or retrograde stent
Definitive treatment depends on the cause
How do you treat a kidney stone?
Ureteroscopy + Laser Lithotripsy
How do you treat a TCC in the upper tract?
Nephroureterectomy
How do you treat an obstruction at the PUJ?
Laparscopic Pyeloplasty
So what tests can you do for a lower urinary obstruction?
- Bladder Scan
- US renal tract
- Cystoscopy
- Digital Rectal Exam
- Urine Flow rate study
How do manage a lower urinary tract obstruction?
Initial resus = Abx, analgesia, fluids as relevant
Emergency management with a catheter to relieve pain etc.
Then treat the cause
How do you treat a urethral stricture?
Optical Urethrotomy
How do you treat meatal stenosis?
Meatal Dilatation
How do you treat phimosis?
Circumcision
