Urinary Tract Obstruction

Question 1

What are the sections of the prostate?

Answer 1

Mcneals Zones
 In --> Out
1) Transition Zone (wraps around urethra
2) Central zone
3) Peripheral Zone (Where most cancers are!!!!!)
4) Ant Fibromuscular Stroma

Question 2

What are Lower Urinary Tract Symptoms (LUTS)?

Answer 2

Split into
Voiding:
- Incomplete Emptying
- Hesitancy
- Poor Stream
- Dribbling

Storage:

• Frequency
• Nocturia
• Urgency/urge incontinence

Other:

• Intermittency
• Straining

Question 3

What physical signs can you detect on exam of a Bladder outflow obstruction (BOO)?

Answer 3

Palpable/percussible Bladder
External urethral meatus stricture
Phimosis
Mass on Digital Rectal Exam (mostly BPH)

Question 4

What tests can you do for a UTO?

Answer 4

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

Question 5

What is BPH?

Answer 5

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

Question 6

How is BPH treated?

Answer 6

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)

Question 7

Example of alpha blocker and 5 alpha reductase inhibitor?

Answer 7

Alpha Blocker - Tamsulosin

5 AR inhibitor - Dutasteride

Question 8

How can a BPH be complicated?

Answer 8

Acute or chronic urinary retention
Urinary Incontinence
UTI
Bladder Stone
Renal Failure (due to hydronephrosis)

Question 9

How can we treat a complicated BPH if they;re not fit for TURP?

Answer 9

• Long term urethral catheter

- CISC (clean intermittent self Catheterisation)

Question 10

Whats the difference between acute & chronic urinary retention?

Answer 10

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.

Question 11

What causes Acute Urinary Retention?

Answer 11

Generally BPH, either as part of the natural progression or paired with some trigger like constipation or a urological procedure.

Question 12

How do you treat Acute Urinary Retention?

Answer 12

Catheterise and start treatment for BPH

Question 13

What causes Chronic Urinary Retention?

Answer 13

Detrusor underactivity.

Largely due to primary bladder failure or a longstanding BOO

Question 14

How do you treat chronic urinary retention?

Answer 14

Catheterisation followed by CISC

Question 15

Chronic urinary retention can be fairly ok or very dangerous, how do you tell?

Answer 15

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

Question 16

What are the major complications when you treat a BOO/urinary retention?

Answer 16

Post-obstructive Diuresis

Decompression haematuria

Question 17

What is post-obstructive diuresis and how do you manage it?

Answer 17

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.

Question 18

What is decompression haematuria?

Answer 18

Shearing of the small vessles during decompression because of different compliance between different tissue layers.
Usually self-limiting

Question 19

UTOs are split into upper and lower tract. What causes each?

Answer 19

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

Question 20

How would an upper tract obstruction present?

Answer 20

• Pain in the flank or loin
• Haematuria (Frank or Micro)
• Palpable mass (maybe)
• Infection/sepsis, renal failure or tumour symptoms

Question 21

What initial management would you use for any obstruction?

Answer 21

• Fluids
• Bloods, ABGs & cultures
• Analgesia
• Broad Spec Abx if signs of infection

Question 22

what investigations can be used for Upper tract obstructions?

Answer 22

US

CT-KUB

Question 23

How do you manage an upper tract obstruction?

Answer 23

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

Question 24

How do you treat a kidney stone?

Answer 24

Ureteroscopy + Laser Lithotripsy

Question 25

How do you treat a TCC in the upper tract?

Answer 25

Nephroureterectomy

Question 26

How do you treat an obstruction at the PUJ?

Answer 26

Laparscopic Pyeloplasty

Question 27

So what tests can you do for a lower urinary obstruction?

Answer 27

• Bladder Scan
• US renal tract
• Cystoscopy
• Digital Rectal Exam
• Urine Flow rate study

Question 28

How do manage a lower urinary tract obstruction?

Answer 28

Initial resus = Abx, analgesia, fluids as relevant

Emergency management with a catheter to relieve pain etc.

Then treat the cause

Question 29

How do you treat a urethral stricture?

Answer 29

Optical Urethrotomy

Question 30

How do you treat meatal stenosis?

Answer 30

Meatal Dilatation

Question 31

How do you treat phimosis?

Answer 31

Circumcision