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Surgery block (Y3) > Urology (4) (Lower Urinary Tract Symptoms) > Flashcards

Urology (4) (Lower Urinary Tract Symptoms) Flashcards

1
Q

LUTS can be split into

A

storage

voiding

post-micturition

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2
Q

storage symptoms

A

urgency

nocturia

frequency

urinary incontinence

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3
Q

voiding symptoms

A

hesitancy

spraying

poor flow

intermittency

straining

terminal dribble

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4
Q

post-micturition

A

post-micturition dribble

feeling of incomplete emptying

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5
Q

storage issues

A

bladder issue

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6
Q

voiding means

A

only when passing urine

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7
Q

in males what can cause voiding symptoms

A
  • Benign prostatic hyperplasia
  • Drugs with an antimuscarinic action (such as tricyclic antidepressants, sedating antihistamines, antimuscarinic drugs for urinary incontinence, and disopyramide).
  • Urethral stricture and phimosis (constriction of the foreskin).
  • Cancer of the prostate, bladder, or rectum.
  • Diabetic autonomic neuropathy and neurogenic bladder.
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8
Q

in males what can cause overactive bladder syndrome

A
  • Benign prostatic hyperplasia and benign prostatic enlargement.
  • Neurological conditions (such as dementia, diabetic neuropathy, multiple sclerosis, Parkinson’s disease, and stroke).
  • Lower urinary tract infection, sexually transmitted infections, and prostatitis.
  • Bladder stones.

Cancer of the bladder and prostate

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9
Q

in males what can cause nocturnal polyuria

A
  • DM
  • Drugs e.g. CCB and diuretics
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10
Q

in males what can cause stress incontinence

A
  • Prostatectomy or other surgery in the pelvic area
  • Injury to the urethral area.
  • Drugs that:
    • Increase urine production (for example alcohol, caffeine, and diuretics)
    • Relax the bladder outlet and urethra (for example alpha-blockers).
    • Can cause urinary retention, which may result in overflow incontinence (for example sympathomimetics [such as pseudoephedrine], drugs with an antimuscarinic action [such as tricyclic antidepressants, sedative antihistamines, and some antipsychotics], and opioid analgesics)
    • Reduce awareness of the need to urinate (for example benzodiazepines and z-drugs [such as zopiclone and zolpidem]).
  • Neurological or muscular conditions (such as multiple sclerosis and spina bifida).
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11
Q

urinary incontinence

A

Urinary incontinence (UI) is the involuntary leakage of urine. It affects around 15% of the general population, most common in the elderly, and is more common in females

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12
Q

RF for UI

A

RF:

  • Age
  • Pregnancy
  • Male: female 1:3
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13
Q

general management for UI

A

General management

  • Bladder diaries
  • QoL questionnaires
  • Urodynamic assessment
  • Cystoscopy
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14
Q

types of UI

A

stress

urge

mixed

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15
Q

stress incontinence

A
  • Urine leakage occurring when the intra-abdominal pressure exceeds the urethral pressure, such as coughing, straining, laughing, or lifting.
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16
Q

causes of stress incontinence

A

The impaired urethral support is most often due to weakness of the pelvic floor muscle.

  • Chronic cough
  • Pregnancy (post partum)
  • Constipation
  • Post-menopausal
  • Obesity
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17
Q

presentation of SUI

A
  • Leakage when coughing or laughing
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18
Q

management of SUI

A
  • Conservative measures
    • PMFT for 3 months 3x a day
    • Duloxetine- stimulates urethral sphincter
  • Surgical intervention
    • Rectus sheath – 10cm- used as hammock to urethra (tension- free vaginal tape)
    • Bladder neck bulking injection
    • Artificial urinary sphincter (last line)
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19
Q

mixed incontinence

A
  • Urge and stress
  • Patient needs to decide which symptoms of urge and stress bother them most- treated accordingly
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20
Q

urge incontinence same as

A

overactive bladder

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21
Q

UUI (OAB)

A

Urge UI describes an overactive bladder (detrusor hyperactivity), which leads to uninhibited bladder contraction, leading to a rise in intravesical pressure and subsequent leakage of urine.

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22
Q

causes of UUI

A
  • Neurogenic causes (such as a previous stroke)
  • Infection
  • Malignancy
  • Idiopathic.
  • Medication, such as anticholinergics, can also result in urge UI.
23
Q

presentation of UUI

A
  • ‘Key in the door scenario’
  • Symptoms
    • Urgency
    • Overactive bladder syndrome
      • Frequency
      • Nocturia
24
Q

conservative management of UUI

A
  • Anticholinergics/ anti-muscarinics
    • Oxybutynin (try for 4 weeks, if intolerable give another)
      • Dry eyes and mouth
      • Constipation
      • Avoid older people
    • B3 agonist- Mirabegron
      • Arrhythmia
      • HTN
      • Palpitations
25
Q

surgical management of UUI

A
  • Botox- under local anaesthetic
    • Inject lining of bladder detrusor
    • Contraindicated in myasthenia gravis
    • Can cause urinary retention- intermittent catheter (until botox wears off)
  • Sacral nerve stimulation- increases inhibition
    • Battery lasts for 5 years
    • Final line- Clam ileocystoplasty
      • It involves cutting open the bladder, like a clam, and sewing a patch of intestine between the two halves.
        • Side effects: issue of detrusor contracting, mucus from bowel tissue, stones
26
Q

Overactive bladder syndrome

A

Overactive bladder (OAB) syndrome is characterised by urgency, often with frequency and nocturia and sometimes leakage (urge incontinence).

  • Secondary to known cause e.g. detrusor muscle overactivity or neurogenic
  • 2nd biggest cause of stress incontinence
27
Q

RF for OAB

A
  • Age
  • Parkinson’s, spinal cord injury, neuropathy, MS, dementia or stroke
  • idiopathic
28
Q

presentation of OAB

A
  • Frequency
  • Nocturia
  • Abdominal discomfort
  • Urge incontinence (in most women)
29
Q

management of OAB conservative

A
  • Lifestyle changes
    • Reduce caffeine
    • Reduce fluid intake
    • Lose weight
  • first line: PFMT
30
Q

drug management of OAB

A
  • Anticholinergic e.g. oxybutynin
31
Q

secondary care management of OAB

A
  • Botulinum toxin A injection
    • Into the bladder wall
    • Nerve stimulation (sacral)
    • Surgical treatment
      • Augmentation cystoplasty
      • Urinary diversion may be considered
        *
32
Q

urodynamic study

A
  • The first part of the tests checks how much urine leaves your bladder over a certain length of time. This is called the flow rate. A special toilet records the flow of your urine. A computer then checks for any abnormalities in flow rate.
  • A decreased flow rate can indicate problems with bladder emptying. For example, this could be an obstruction to bladder drainage or underactivity of your bladder muscle.
  • The second part of the tests is called filling cystometry. For this test, thin tubes called catheters are inserted into your bladder and your back passage (rectum) or your vagina. These can measure the pressure in your bladder and tummy (abdomen) as your bladder fills with fluid. Using these measurements, doctors compare the different pressure readings.
  • If urine leaks with no change in pressure in your bladder muscle, you may have stress incontinence. Leaking is brought on by an increase in pressure inside your abdomen - for example, when coughing.
  • If involuntary bladder muscle activity causes an increase of pressure in your bladder and leads to leaking, you may have urge incontinence
33
Q

chronic urinary retention

A

Chronic urinary retention is the painless inability to pass urine*. These patients have long standing retention, therefore have significant bladder distension which results in bladder desensitisation, therefore minimal discomfort despite potential large intra-vesical volumes.

34
Q

causes of chronic urinary retention

A
  • BPH
  • Urethral strictures
  • Prostate cancer
  • Pelvic prolapse in women (cystocele, rectocele, uterine prolapse)
  • Pelvic masses
  • Neurological causes
35
Q

presentation of chronic urinary retention

A
  • Painless urinary retention
  • Voiding LUTS such as weak stream and hesistancy
  • Reduced functional capacity
  • Overflow incontinence
  • Nocturnal enuresis
  • Palpable distended bladder with no tenderness
36
Q

investigation for chronic urinary retention

A
  • Post-void bedside bladder scan- shows volume of retained urine
  • Routine blood tests
  • If high pressure retention- US to look for hydronephrosis
37
Q

management of chronic urinary retention

A
  • Patients with very high post-void volumes (arbitrarily >1L) or evidence of high pressure retention should be catheterised with a long-term catheter. Those with high post-void volumes should also have urine output monitored for post-obstructive diuresis
  • Definitive management of chronic retention depends on the underlying cause.
38
Q

why should patient with chronic urinary retention not undergo trial without catheter (TWOC)

A
  • The patients should not undergo a Trial WithOut Catheter (TWOC), especially if evidence of high-pressure chronic retention, due to concerns of repeat renal injury. Instead they should have a long-term catheter before definitive management is planned; alternatives to this include ISC or suprapubic catheterisation.
39
Q

Complications of chronic urinary retention

A
  • Urinary tract infections
  • Bladder calculi
  • Chronic kidney disease- high pressure retention
40
Q

acute urinary retention

A

Acute urinary retention is defined as a new onset inability to pass urine*, which subsequently leads to pain and discomfort, with significant residual volumes.

41
Q

RF acute urinary retention

A
  • Older male patients
42
Q

causes of acute urinary retention

A
  • BPH
  • Urethral stricture
  • Prostate cancer
  • UTI (can cause the urethral sphincter to close)
  • Constipation
  • Severe pain
  • Medications (anti-muscarinic or spinal or epidural anaesthesia)
  • Neurological causes (peripheral neuropathy, nerve damage, UMN disease)
43
Q

presentation of acute urinary retention

A
  • Acute suprapubic pain
  • Inability to micturate
  • Palpable distended bladder
  • Suprapubic tenderness
  • PR examination
    • Prostate enlargement
    • Constipation
44
Q

investigations of acute urinary retention

A
  • Post void bedside bladder scan will show the volume of retained urine
  • Routine bloods
  • MSU
  • US looking for hydronephrosis
45
Q

management of acute urinary retention

A
  • Immediate urethral catherization
  • Underlying cause treated e.g. BPH0 tamsulosin
  • Review of patients medication
46
Q

definitive management of acute urinary retnetion

A
  • Patients with large retention volume (>1000ml) need to be monitored post catherization for evidence of post-obstructive diuresis
  • Patients with high pressure urinary retention
    • Keep catheter in Situ until definitive management e.g. TYRP
  • If no evidence of renal impairment -TWOC (catheter removed 24-48hrs after insertion)- if pt voids successfully then successful
47
Q

complications of acute urinary retention

A

AKI which can lead to CKI

48
Q

neurogenic bladder causes

A
49
Q
A

Neurogenic bladder can be congenital (present at birth). Birth defects that can cause neurogenic bladder include:

  • Spina bifida (myelomeningocele): This disorder occurs when the spine doesn’t completely develop during the first month of pregnancy. Babies born with myelomeningocele often have paralysis or weakness that affects how their bladder works.
  • Sacral agenesis: This is a condition in which parts of the lower spine are missing.
  • Cerebral palsy: Cerebral palsy refers to a group of chronic (long-term) disorders that weaken a person’s ability to control body movement and posture. These disorders result from injury to the motor areas of their brain. The problem causing cerebral palsy may occur while during development or after birth. Cerebral palsy isn’t always found during a child’s first year of life.

Medical conditions that involve the nervous system can cause neurogenic bladder. Common causes include:

Other conditions include:

50
Q

high pressure urinary retention

A
  • High Pressure Urinary Retention refers to the urinary retention causing such high intra-vesicular pressures that the anti-reflux mechanism of the bladder and ureters is overcome and ‘backs up’ into the upper renal tract leading to hydroureter and hydronephrosis, impairing the kidneys’ clearance levels.
  • Such patients present in retention with associated deranged renal function, and hydronephrosis will be subsequently confirmed on imaging (typically ultrasound as first line). Repeat episodes of high-pressure chronic retention can cause permanent renal scarring and chronic kidney disease (CKD).
51
Q

low pressure urinary retention

A

occurs in patients with retention with the upper renal tract unaffected due competent urethral valves or reduced detrusor muscle contractility / complete detrusor failure.

52
Q

Post-Obstructive Diuresis

A

Following resolution of the retention through catheterisation, the kidneys can often over-diurese due to the loss of their medullary concentration gradient, which can take time to re-equilibrate.

This over-diuresis can lead to a worsening AKI. Consequently, those patients at risk should have their urine output monitored over the following 24 hours post-catheterisation.

  • Patients producing >200ml/hr urine output should have around 50% of their urine output replaced with intravenous fluids to avoid any worsening AKI.
53
Q

residual volumes for acute retention

A

Acute

  • Painful inability to void
  • Residual volume 300-1500ml
    • Will only get up to 1500ml acute on chronic cause

Surgery block (Y3) (38 decks)

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