Urology E84-87

Question 1

84. What is Urinary Retention?

Answer 1

It is when urine remains in the bladder. It is characterised by poor urinary stream with intermittent flow, straining and a sense of incomplete voiding and hesitancy.

As the bladder remains full it can cause incontinence, nocturia and high frequency

Question 2

84. Another name for Urinary Retention?

Answer 2

Ischuria

Question 2

84 Why is acute retention a medical emergency?

Answer 2

Bladder can distend and become painful. Increase in pressure in bladder can cause urine to pass back into ureters and kidneys causing hydronephrosis, kidney failure and sepsis

Question 2

84 Dx of urine retention?

Answer 2

Cystoscopy, retrograde cystourethrography to evaluate for bladder stones, strictures or tumours

Urodynamic studies such as uroflowmetry, cystometry to evaluate bladder function in patients with neurogenic bladder to help guide management

Question 3

84 Causes of urine retention?

Answer 3

1. Structural\Mechanical: bladder stone in bladder neck, tumour, BPH, Prostate cancer, Foreign body
2. Functional (neurogenic) – post op urine retention, injury to the spine, tetanus, certain drugs (anticholinergics)

Question 4

84 Treatment for urine retention?

Answer 4

Bladder drainage via catherisation can be urethral or suprapubic. Urethral stents can also be used for urethral strictures.prostate medications and surgery

Question 5

84 What are the different types of catheters?

Answer 5

1. Foley: 2 way (irrigation and urine) or 3 way (blood)
2. Nelaton – can be straight or curved. Needs to be fixed to skin with tape or suture

Question 6

84 Which catheter is longer male or female? Why?

Answer 6

Males need longer catheters due to longer urethra

Question 7

84 How is a suprapubic catheter placed?

Answer 7

• Clean region with iodine and cleaning solution
• Palpate for bladder
• Use local anesthestia
• Make a small incision few inches below the navel
• Insert catheter using stamey device. It has a piece oof metal called obturator to guide catheter
• Remove obturator once catheter in bladder
• Inflate balloon
• Clean insertion area and stich opening

Question 8

84 Why should you only release 200ml of urine first then wait?

Answer 8

Releasing all the urine in the bladder can risk constriction of vessels leading to haematuria.

Question 9

84 What is suprapubic drainage?

Answer 9

Suprapubic incision to allow catheter to enter bladder through pelvis and skin.

Typically use cystofix or vesicotomy

Question 10

85 Definition of urinary incontinence

Answer 10

Involuntaryy leakage of urine. Due to loss or weakened control of bladder

Question 11

85 What nerve innervates control of urinary sphincter?

Answer 11

hypogastric nerve

Question 12

85 What is urge incontinence?

Answer 12

Uncontrolled urine leakage moderate to large volume that occurs after urgent need to void. Nocturia and nocturnal incontinence common. Most common in elderly

Men – due to enlarged prostate that cause bladder to drop and irritate urethra
Women – atrophic vaginitis, aging,

Question 13

85 What is stress incontinence?

Answer 13

Urine leakage due to sudden increase in intra-abdominal pressure (coughing laughing) leakage is low to moderate volume

Men – after procedures like radical proctectomy, stress incontinence more severe in obese due to pressure of abdominal contents

Women – 2nd most common type of incontinence in women, can be due to pregnancy and complications of childbirth, development of atrophic urethritis

Question 14

85 What is overflow incontinence?

Answer 14

Dribbling of urine from a full bladder. Volume is small but leak can be constant so adds up over time. Occurs when there is an obstruction or blockage to the bladder urinary stones, tumour etc

Question 15

85 What is functional incontinence?

Answer 15

Urine loss due to congintive or physical impairments (demntia stroke) e.g. pt may not know they need to go or are unable to get to the toilet in time

Question 16

85 What is Mixed incontinence?

Answer 16

Combination of urge, stress, overflow or functional incontinence. Most common being urge with stress and urge or stress with functional

Question 17

85 What is gross total incontinence?

Answer 17

Leaks urine continuously or has period of uncontrollable leaking of large amounts of urine can be due to anatomical defect Eg. Fistula from bladder to vagina or spinal cord injury.

Question 18

85 Risk Factors for urinary incontinence?

Answer 18

Obesity (increased pressure) smoking (chronic cough=increase intraabdominal pressure), age (weak bladder muscles), diseases (spinal cord injury, kidney disease, diabetes, prostate disease)

Question 19

85 Dx for urinary incontinence?

Answer 19

1. Physical exam, urinalysis, blood test (assess kidney function0
2. Postvoid residual measurement
3. Cystogram – x-ray to visualise bladder, cystoscopy, pelvic ultrasound

Question 20

85 Tx for urinary incontinence?

Answer 20

Kegel exercises
Bladder training – delaying event to control urge
Double voiding – urinating, wait few mins then go again

Medication
Surgery

Catheter and bag, absorbent pads

Question 21

85 Medications for urinary incontinence?

Answer 21

Anticholinergics – calm overactive bladder
Topical oestrogen – reinforce tissue in the urethra and vaginal areas and lessen symptoms

Question 22

85 Surgery tx of urinary incontinence?

Answer 22

Sling procedures – mesh inserted under the neck of bladder to support the urethra and stop leakage

Colposuspension – bladder neck is lifted can help with stress incontinence

Artificial sphincter – artificial sphincter valve can be inserted to control flow of urine from bladder into urethra

Question 23

86 Def of Urinary obstruction

Answer 23

Blockage of the flow of urine out of the body. Common cause of acute and chronic renal failure

Question 24

86 Classification of urinary obstruction

Answer 24

Cause – congenital, acquired
Duration – acute, chronic
Degree – partial, complete
Level – upper, lower

Question 25

86 Causes of urinary obstruction in kids

Answer 25

Urethral and bladder outlet obstruction – urethral atresia, phimosis, meatal stenosis

Ureteral obstruction – vesicoureteral reflux, uretocele, prune belly syndrome

Question 26

86 Causes of urinary obstruction in adults

Answer 26

Urethral and bladder outlet obstruction – phimosis, stricture, trauma, bph, bladder cancer

Ureteral obstruction – vesicoureteral reflux, inflammatory bowel disease, carcinoma of ureter, uterus, prostate, bladder colon or rectum

Intrarenal obstruction – protein casts, crystals

Question 27

86 Pathogenesis of urinary obstruction

Answer 27

Upper tract: Ureter: in the early stages intravesical pressure is normal but later the added stretch effect at the lower end of the ureter induces further hydroureteronephrosis. Finally due to the increased pressure the ureteral wall becomes attenuated losing its contractile power at the stage of decompensation.

Mid tract: stage of compensation – bladder musculature hypertrophies
Stage of decompensation – large obstructing gland can be palpated rectally or observed on cystoscopy

Lower tract: obstruction – proximal hydrostatic pressure causes dilation of urethra resulting in thinned urethra walls which then form diverticulum leading to infected urine extravasation resulting in periurethral abscess

Question 28

86 Symptoms of urinary obstruction?

Answer 28

Reduced flow w/wo pain. Altered patterns of urination, acute or chronic renal failure, haematuria (gross or microscopic), new onset or poorly controlled hypertension

Question 29

86 Dx of urinary obstruction?

Answer 29

Physical exam urinalysis
Serum electrolytes, blood urea nitrogen creatinine, calcium, phosphate, uric acid, albumin

CT – shows stones etc

MRI

IV pyelography –

Ultrasonography – procedure of choice in determining hydronephrosis

Question 30

86 Treatment of urinary obstruction

Answer 30

Main aim is the reestablish urinary flow.
Catheter can be placed
Stones are most common cause of unilateral ureteral obstruction can be managed conservatively with small stones. Surgical drainage for patients with severe pain, or persistent obstruction

Extracorporeal shock wave lithotripsy for other stones

pharmacological treatment for bph etc

Question 31

87 Hydronephrosis Def

Answer 31

Aseptic dilation of whole or part of the kidney due to partial or complete obstruction of urine outflow. Can be bilateral or unilateral.

Question 32

87 What is hydocalycosis?

Answer 32

Obstruction and dilation of the neck of the calyx

Question 33

87 Causes of hydronephrosis?

Answer 33

Unilateral:
aberrant renal vessels, involvement of ureter by tumours of cervix, prostate, congenital stenosis at the pelviureteric junction, inflammatory stricture, stone in the ureter

Bilateral:
Congenital – congenital stenosis of urethral meatus or congenital bladder neck
Acquired – bladder neoplasm, retroperitoneal fibrosis, urethral structure or phimosis, BPH

Question 34

87 Classification of Hydronephrosis

Answer 34

According to flow:
Open, closed or intermitted

According to shape:
Pelvic: when pelvis is extra renal and dilation affects the pelvis more than the kidney
Renal: pelvis is intrarenal and remains small while calyces dilate with atrophy of the renal cortex resulting in rapid destruction of the renal parenchyma
Calyceal: due to obstruction of the calyces

Question 35

87 Clinical features of hydronephrosis

Answer 35

More predominant in women.
In unilateral cases it is more common in the right side with dull ache or heaviness, can also experience ureteric colic attacks
Bilateral has dull ache in loin

General sx: nausea, vomiting, dysuria, incomplete voiding, fever

Question 36

87 Dx of hydronephrosis?

Answer 36

Cystourethroscopy for causative lesion in bladder and prostate.
Xray abdo showing calcification, stone or enlargement of renal shadow

Question 37

87 Treatment of hydronephrosis

Answer 37

Treat the cause ( stone, stricture, tumour, stenosis, ligation of aberrant vessel)

Reconstruction of the pelvis via pyeloplasty, 2 types of pyeloplasty – dismembering and non-dismembering

Nephrectomy for advanced unilateral cases

Indications for surgery attacks ofo renal pain, increasing dilation of pelvis

Question 38

87 Def of Pyonephrosis

Answer 38

Septic dilation of renal pelvis and its calyces. Kidney full of pus

Question 39

87 Types of pyonephrosis

Answer 39

Primary = complication of pyelonephritis
Secondary – due to infection of hydronephrotic kidney by blood borne infection
Open or closed

Question 40

87 Pathology of pyonephrosis

Answer 40

E.coli most common cause. Other causative agents include enterococcus, candida, Klebsiella, pseudomonas, tuberculosis, staphylococcus sp. etc.
Pelvis and calyces are full of pus with mucosal ulceration, parenchyma is atrophied

Question 41

87 Clinical features of pyonephrosis

Answer 41

Triad of anaemia, fever, swelling in loin. Frequent urination pyuria

Question 42

87 Dx of pyonephrosis

Answer 42

Urinalysis, urine culture. Xray to show stone or calcification.
Intravenous ultrasonography shows nonfunctioning kidney or delayed function of kidney

Question 43

87 Tx of pyonephrosis

Answer 43

Removal of obstructive cause with heavy dose antibiotics (gentamicin and ampicillin) clindamycin for anaerobic bacteria coverage

Nephrectomy in advanced unilateral pyonephrosis.
Solitary kidney or bilateral with advanced condition, nephrostomy