Urinary Tract Obstruction & LUTS

Question 1

Where can Renal obstruction occur

Answer 1

Uni or bilateral

May occur anywhere from the renal calyces to the urethral meatus can be a partial or a complete obstruction

Question 2

What are the clinical features of acute upper tract obstruction

Answer 2

Loin to groin pain
There may be superimposed infection +/- loin tenderness
Enlarged kidney

Question 3

What are the features of chronic upper tract obstruction

Answer 3

Flank pain
Renal failure
Superimposed infection
Polyuria may occur due to impaired urinary concentration

Question 4

Features of acute lower tract obstruction

Answer 4

Acute urinary retention - suprapubic pain, +/- acute confusion (elderly)
Usually acute on chronic
Clinically - distended, palpable bladder, dull to percussion

Question 5

Chronic lower tract obstruction

Answer 5

LUTS symptoms

Question 6

What are LUTS symptoms

Answer 6

Storage and voiding symptoms
Voiding - hesitancy, poor flow, post micturition dribbling, straining and the feeling of incomplete emptying
Storage - urgency, nocturia, frequency inc, incontinence

Question 7

What score is used to address the severity fo the symptoms

Answer 7

IPSS
International prostate symptoms score
8 question written screening tool to diagnose, Tracy the symptoms of and suggest the Mx of BPH

Question 8

Symptoms to ask for in a bladder history

Answer 8

Bladder Hx - 
Frequency 
Urgency 
Nocturia
Incontinence
Hesitancy 
Urinary flow
Post micturition dribble 
Incomplete voiding
Dysuria 
Haematuria
Suprapubic pain or discomfort 
Fluid intake - coffee tea - diuretics 
PMH - surg, 
DHx
FHx

Question 9

Examination of LUTS

Answer 9

Abdo - palpable bladder
Pain - acute
Painless - chronic
Ballottable kidneys
Examine external genitalia
Examine the back - neurological signs - spinal dysraphism, surgery - these causes of the urinary problems
Saddle sensation
DRE- examine the rectum and visible abnormalities, fecal impaction, feel the prostrate - size surfaces
Nodular on either side alter the request a PSA and TRUS biopsy

Question 10

Investigation of LUTS

Answer 10

Serum creatinine estimation
Urine dip - blood, sugar, infection, protein, MC&S

IPSS
Frequency volume chart
Urine flow test
Estimation of post micturition residual volume

Serum PSA
US of urinary tract

Question 11

What can cause urinary tract obstruction

Answer 11

Luminal:stones, blood clot, sloughed papilla, tumour:renal, ureteric, bladder
Mural: congenital or acquired stricture, neuromuscular dysfunction
Extra mural : abdominal or pelvic mass/tumour, retroperitoneal fibrosis, or iatrogenic - post surgery

Question 12

What bladder obstruction may be clinically silent

Answer 12

Unilateral as one kidney can take over the tasks - so can have normal outflow and U&Es

Question 13

Tests to do in bladder obstruction

Answer 13

U&E 
Creatinine
 FBC
PSA
Urine dip
MC&S
US - hydronephrosis, hydroureter
Bladder scan after weeing to see how much urine isn’t being voided
CT scan 
KUB

Question 14

Tx upper obstruction

Answer 14

Nephrostomy

Or ureteric stent

Question 15

Tx lower tract obstruction

Answer 15

Insert urethral or suprapubic catheter
To relieve acute retention
In chronic obstruction only catheterise patient if there is pain, infection or renal impairment
Intermittent self-catheterisation may be required
Clot retention 3 way bladder wash out catheter
TWOC

Question 16

Problem of ureteric stenting

Answer 16

Common
Stent related pain
Trigonal irritation
Haematuria
Fever
Infection
Tissue inflammation
Encrustations
Biofilm formation
Rare
Obstruction
Kinking
Ureteric rupture
Stent misplacement
Stent migration
Tissue hyperplasia
Forgotten stents