Week 6: Womens' health (3) (urinary symptoms) Flashcards
urinary frequency
high frequency with normal 24-hour volume
polyuria
passing more urine than usual (up to 3l of urine in 24horus is normal)
nocturia
waking at night to urinate
hesitancy
difficult urinating i.e. starting stream or keeping it going
anuria
no urination
Lower urinary tract symptoms (LUTS) cna be split into
storage symptoms
voiding symptoms
post-micturition symptoms
storage symptoms
- Polyuria
- Nocturia
- Urgency
- Incontinence
- Stress
- Urge
- Mixed
- Enuresis
- Bladder sensation (normal, increased, reduced, absence, non-specific)
voiding symptoms
- Slow stream
- Spraying
- Hesitancy
- Terminal dribble
- Straining to void
post micturition
- Feeling of incomplete emptying
- Post micturition dribble
causes of LUTS in women
- UTI
- UI
- anxiety
- Overactive bladder
- bladder tumour or stone
- prolapse
- urinary tract stone
- neurological disease
RF for LUTS in women
- Age
- Being overweight
- Number of children
- Abnormalities of urogenital system
- Pelvic organ prolapse
- Female genital tract abnormality
presentation of lUTS in women
-
overactive bladder
- urgency, frequency, nocturia, UI
-
infection
- dysuria
- urinary frequency
-
voiding symptoms
- urinary retention, poor stream, hesitancy, terminal dribble
-
postmicturition symptoms
- dribble
- feeling of incomplete bladder emptying
-
sexual intercourse
- dyspareunia
- vaginal dryness
-
genitourinary prolapse
- something coming down, low backache, dragging sensation
investigations for LUTS in women
- urine: urinalysis, MSU, pregnancy test, haematuria, infection
- renal function and electrolytes, FBG
- frequency chart, bladder diary, genitourinary swaps
- intravenous pyelogram
- US
- urodynamic studies
- cystoscopy
general management of LUTS in women: UTI
non-pharmacological
- bladder emptying after sex
pharmacological
- antibiotics
general management of LUTS in women: Urinary incontinence / oAB
Non-pharmacological
- PFMT to prevent UI
- reduce caffeine intake
- reduce weight if >30kg/m2
- bladder training
pharmacological
- Stress- duloxetine
- OAB- oxybutinin/ mirabegron /botulinum
- urethral tape
general management of LUTS in women: prolapse
- ring pessaries may be useful where surgery for prolapse not possible
- reduce weight if >30kg/m2
general management of LUTS in women: nocturnal enuresis or diabetes insipidus
- desmopressin
LUTS in men
- storage, voiding and postmicturition symptoms affecting the lower urinary tract
- reduces quality of life
- LUTs are common and not necessarily a reason for suspecting prostate cancer
- most common problems
- nocturia
- outflow symptoms
causes of LUTS in men
- BPH with obstruction
- detrusor muscle weakness
- UTI
- urinary tract stones
- malignancy : prostate or bladder cancer
- neurological disease e.g. MS
- polyuria secondary to DM
RF for LUTS
- increase serum dihydrotesterone levels
- obesity
- elevated fasting glucose/diabetes
- inflammation
- NSAIDs decrease risk
presentation of LUTS in men: storage
- urinary frequency, urgency, dysuria, nocturia
presentation of LUTS in men: voiding
- : poor stream, hesitancy, terminal dribble, incomplete voiding, overflow incontinence
general red flags for LUTS presentation
- haematuria, fever, loin and pelvic pain- UT
signs of LUTS in men
- palpable bladder
- rectal exam (prostate: size, tenderness, nodules)
investigations for LUTS in men
- history to identify possible causes and comorbidities
- exam of abdomen
- urine dipstick
- urinary frequency volume chart
- renal function test
- DRE
general management of LUTS in men: storage symptoms
conservative
- OAB- bladder training, advice on fluid intake, lifestyle
- PFMT for men with stress UI caused by prostatectomy
- containment products e.g. catheter/ pads /collecting devices
pharmacological
- overactive bladder- anticholinergic
- nocturnal polyuria- late afternoon loop diuretic
general lifestyle management for LUTS
- reduce fluid intake (but not too much) containing alcohol, caffeine and artificial sweetners
- distraction techniques such as breathing exercises
general management of LUTS in men: voiding symptoms
conservative
- intermittent bladder catherization
- bladder training less effective than surgery
pharmacological
- BPH- alpha blocker e.g. tamsulosin
general management of LUTS in men: acute vs chronic retention
- acute retention
- catheterise
- offer alpha blocker before removing catheter
- chronic retention
- catheterise
- surgery if symptoms are bad
urinary incontinence
Complaint of any involuntary leakage of urine… associated with…
- Massive impact on QoL
- Social exclusion
- Sense of shame
- Just put up with it attitude
types of incontinence SUMO
stress
Urge
mixed
overflow
stress incontinence
- Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing
- In men: Abdominal abnormality involving supporting tissues around bladder nec and proximal urethra
- In female: pregnancy, childbirth, older age- weakened pelvic floor
- Treatment: PFMT, surgery
urge incontinence
- The complaint of involuntary leakage (or urine) accompanied by or immediately proceeded by urgency e.g. key in door scenarios
- Cause: overactive contraction of detrusor muscle, diabetes, Alzheimer’s, Parkinsons, MS, stroke
mixed urinary incontinence
- The complaint of involuntary leakage (or urine) associated with urgency and also with exertion, effort, sneezing or coughing
overflow incontinence
- Caused by an obstruction or blockage in bladder à prevents from fully emptying
Functional incontinences
Is common in older people. In this type of incontinence, there are no particular stress or urge symptoms: the aetiology is often related to a combination of wider health problems (e.g. disability, cognitive impairment, mobility problems).
management of urge incontinence
- advice on fluid intake and lifestyle measure
- referral for bladder training
- if symptoms persist
- anticholinergic drug e.g. oxybutynin/ mirabegron (medication can take at least 4 weeks to work)
management of stress incontinence
- reduce caffeine
- reduce fluid intake
- weight loss if >30kg/m2
- reduce smoking
- supervised pelvic floor muscle training
- absorbent containment products
- pads
- pharmacology: duloxetine (only if women prefers drugs to surgical treatment)
- surgery
acute urinary retention
- sudden inability to pass urine
- usually painful and requires emergency treatment with a catheter
causes of acute urinary retention in men
BPH, meatal stenosis, paraphimosis, penile constricting bands, phimosis, prostate cancer, balanitis, prostatitis, prostatic abscess
causes of acute urinary retention in women
prolapse (cystocele, rectocele, uterine), pelvic mass (gynaecological malignancy, uterine fibroids, ovarian cyst)
causes of acute urinary retention in both
- bladder calculi, bladder cancer, faecal impaction, GI malignancy, urethral stricture, foreign bodies, UTI
drugs which cause urinary retention
anticholinergics, opioids, anaesthetics, alpha-adrenoreceptor agonists, benzos, NSAIDs, alcohol, CCB
neurological causes of urinary retention
- peripheral nerve e.g. DM, Guillain-Barre syndrome, pernicious anaemia
- brain: stroke, MS, Parkinson’s
- spinal cord: invertebral disc. disease, meningomyelocele, MS, cauda equina)
presentation of acute urinary retention
- unable to pass urine
- extreme discomfort
- tender, distended bladder
Investigations of acute urinary retention
- urinalysis (infection, haematuria, proteinuria, glucosuria)
- MSU
- blood tests (FBC, U and E, PSA)
- imaging
- US – hydronephrosis, post voidal residue
- CT scan, look for masses
- MRI? CT brain scan looking for intracranial lesion
- MRI of spine- cauda equine, prolapse
- urodynamic studies
- cystoscopy
management of acute urinary retention
- immediate bladder decompressionà catherization (offer alpha-blocker before removal of catheter)
- dependent on cause
- e.g. prostatic surgery if BPH
- TWOC – trial without catheter standard practice
chronic urinary retention
- describes a bladder that does not empty completely
- can cause LUTS symptoms
- not immediately life-threatening
- can lead to hydronephrosis and renal impairment and puts the patient at risk of acute-on chronic retention
chronic urinary retention causes
- BPH is the most common
- prostatic carcinoma
- drugs
- antispasmodics
- antihistamines
- anticholinergics
- congenital deformities
- urethral strictures
- infection e.g. tb, gonorrhoea
- trauma e.g. fractured pelvis, iatrogenic
- risk factors
- more common in men
presentation of chronic urinary retention
- some patients with chronic urinary retention do not have any symptoms
- urinary frequency, urgency, hesitancy
- poor urinary stream
- post-micturition dribbling
- nocturia
- UI
- sensation of incomplete voiding
- UTI
- acute urinary retention
investigations of chronic urinary retention
- urinalysis
- MSU for microscopy
- blood tests (U&Es, FBC, blood glucose, PSA)
- voiding diary
- imaging
management of of chronic urinary retention
- intermittent or indwelling self-catheterisation before offering surgery
- stop precipitating medication
- lifestyle e.g. reduce fluid ,alcohol, caffeine
- bladder training
- surgery- if cause of retention
- drugs
- BPA- alpha blockers e.g. tamuslosin- relaxes urinary tract
- alpha 5 reductase inhibitor e.g. finesteride- takes 6 weeks
- BPA- alpha blockers e.g. tamuslosin- relaxes urinary tract
Post obstructive diuresis
- Following resolution of urinary retention through catheterization
- Kidneys can often over diureseà over filter
- Can lead to worsening AKI
- Can lose Countercurrent- more water loss
- Urine output should be monitored for 24h post catheterisation
- Patients with high urine volumes should be supported with IV fluids
- Prevent dehydration
Hydronephrosis
Dilation of the renal pelvis and calyces due to obstruction at any point in the urinary tract causing increased pressure and blockage. It can be:
- Unilateral- caused by upper urinary tract obstruction
- Bilateral- caused by obstruction in the lower tract
hydronephrosis results in
- Progressive atrophy of kidney develops as the back pressure from the obstruction transmitted to the distal part of the nephron
- GFR declines, if bilateral= renal failure
diagnosis of upper urinary tract obstruction
- USS or
- Only tell structural problem not functional problem
- CT scan- can show stones high in calcium
- Only tell structural problem not functional problem
-
Diuretic renography (MAG3) = functional test
- Give furosemide to increase diuresis
Diuretic renography (MAG3) = functional test
- Can see that in a normal urinary tract after giving furosemide you get a flow of liquid
- In obstructed giving furosemide will not change activity
enuresis in children
- Bedwetting = involuntary wetting during sleep at least 2x/week in children aged >5 yrs with no CNS defects
- Key questions
- Age?
- Primary or secondary?
- Never achieved sustained continence at night (primary)
- Restarted having been dry at night for 6+ months (secondary)
- Do they have daytime symptoms?
- Do they have pain passing urine or pass urine infrequently?
- Are they constipated?
management of enuresis in patients without daytime symptoms
- Usually managed in primary care
- Reassurance, alarms with positive reward system, ?desmopressin (man made vasopressin)
management of enuresis in pt with daytime symptoms
- Usually caused by disorders of the lower urinary tract e.g. anatomical, OAB
- NICE recommends referral to secondary care
management of secondary enuresis
- Treat underlying cause if it has been identified e.g. UTIs, constipation, diabetes, psychological problems, family problems, physical or neurological problems
- Primary/secondary care
flow volume chart
like diary
- Frequency — high frequency with normal 24-hour volume
- Polyuria (passing more urine than usual) — up to 3 L of urine in 24 hours is normal.
- Nocturia (waking at night to urinate).
- Nocturnal polyuria (passing, at night, more than 35% of the 24-hour urine production).
benign prostatic hyperplasia
- increase in the number of cells e.g. ‘plasia’ or ‘trophy’à glandular enlargement of the prostate
- without malignancy
- common in advancing age
- failure of apoptosis
presentation of BPH
- urinary frequency
- urinary urgency
- hesitancy
- incomplete bladder emptying
- push or strain
- UTI
- urinary retention
investigation of BPH
- DRE
- It should be firm but not hard, and smooth without nodules. The median sulcus should be clearly defined. A gland that is hard rather than firm, nodular and lacks a clear median sulcus suggests carcinoma of prostate.
- urine- dipstick and MSU
- blood (U&Es, FBC, LFTS, PSA)
- PSA
- is elevated with a large, benign prostate → needs to be combination of clinical examination
management of BPH
- alpha-adrenergic antagonists or alpha blockers e.g. tamsulosin
- 5-alpha reductase inhibitor (5-ARI) e.g. finasteride
- takes months to work
- reduce long-term risk of acute retention or need for surgery
- can cause problems with libido and erectile dysfunction
- surgery- for those with large prostate or inadequate response to therapy e.g. transurethral resection of the prostate (TURP)
Carcinoma of the prostate
- Commonest cancer in men
- 2nd commonest cause of death from cancer in men
- 1 in 8 men will be diagnosed with prostate cancer
- Rare in men <59
RF for prostate cancer
- Increased age
- Family history (BRACA2 gene mutation)
- Ethnicity
- Black > White >Asian
zones of the prostate
Lesions most commonly found in the periphery of the posterior part of the prostate
prostate cancer
BPH hypertrophy occurs
in the central location
presentation of prostate cancer
- urinary symptoms
- UTI
- Prostatism
- raises PSA
- opportunistic finding from rectal exam
- indicdental fidning at transurthral resection of the prostate
- Metastatic disease in the bone (usually spine) causing bone pain
PSA and prostate cancer
- Increasingly found following investigation of elevated prostate- specific antigen (PSA) in otherwise asymptomatic man
- Prostate specific antigen (PSA)
causes of raised PSA
- Prostate cancer
- Infection
- Inflammation
- Large prostate
- Urinary retention
classification of prostate cancer
Gleason classification is used to grade tumours on histological appearance
- Grade 1
- Well differentiated tumour composed of uniform cells
- Grade 5
- Anaplastic diffuse tumour with cells showing great variation in their structure and high mitotic rate
diagnosis of prostate cancer
- DRE : hard and irregular prostate
- US: used to define prostatic mass
- Increased PSA level in blood
- Biopsy of prostate- histological diagnosis
- Radiographs and bone scans sued to stage the tumour
treatment of localise dprostate cancer
- Treatment options include surgery, hormone therapy and radiotherapy
- Before treatment is started a histological diagnosis of prostatic carcinoma is require.
- Treatment depends on stage of tumour
- T1/T2: radical surgical resection of the prostate may be curative. TURP may be required
- Local radiotherapy can be used if the pt is unfit for surgery and to treat local or distant spread of the tumour
- Surveillance
treatment of advanced prostate cancer
- Hormonal manipulation is beneficial since testosterone promotes tumour growth
- Testosterone
- Dihydrotestosterone (potent)
- Therefore to reduce testosterone
- Surgical castration or
- Medical castration (LHRH and GnRH agonists)
- Both would promote T release initially (5-6 weeks)
- Can cause depression (may give androgen blockers)
- However overtime this will stop testosterone release
- Both would promote T release initially (5-6 weeks)
- Palliative care
prognosis of prostate cancer
- 5 year survival rate for T1 tumours is 75-90%
- However 5 year survival falls to 30-45% if there is local or metastatic spread
types of renal cancer
renal cell carcinoma transitional cell carcinoma
renal cell carcinoma
90%
-
Presents in parenchyma of the kidneys
- Pyramids
- Cortex
- Medulla
-
Epidemiology
- Arise from tubular epithelium
- Rare in children (peak incidence 60-70)
- can be staged
RF of RCC
- Male: female ratio 3:1
- Risk factors
- Dialysis
- Smoking
- Obesity
presentation of RCC
- haematuria or incidental finding
- Non specific symptoms
- Fatigue
- Weight loss
- Fever
- May be mass in loin
- RCCs often metastasize before local symptoms develop
- If advanced
- Small number can secrete hormone like substances such as PTH-rP (pts present with hypercalcemia)
- Large varicocele may be presence
investigations for RCC
- Radiology- US or CT
- Endoscopy- flexible cystoscopy
- Urine- cytology
treatment of RCC: localised
- Localised RCC
- Surveillance
- Increasingly small tumours removed with partial nephrectomy to preserve some renal function
- For large tumours with no distant metastases treatment involves a radical nephrectomy with removal of the associated adrenal gland, perinephric fat, upper ureter and the para-aortic lymph node
treatment of metastatic RCC
- Little effective treatment for metastatic disease
- Chemotherapy and radiotherapy resistant
- Palliative treatment- target angiogenesis
transitional cell carcinoma
- Can affect anywhere from the calyx to the bladder
- Most commonly found in bladder
presentation of TCC
- Haematuria
- Incidental finding on imaging (US or CT)
- Weight loss
- Loss of appetite
- Signs/symptoms of obstruction
RF of TCC
- Analgesic misuse
- Exposure to aniline dyes used in the industrial manufacture of dyes, rubber and plastics
- Smoking
- Male to female ratio is 3:1
- Can be diagnosed and treated by transurethral resection of bladder tumour (TURBT)
staging of TCC
- 75% are superficial
- 5% are Tis this is carcinoma in situ (CIS) or flat tumour
- 20% are muscle invasive
- Tumours are also graded
- Worse prognosis if it has invaded muscle
diagnosis of TCC
- Investigation via cystoscopy and biopsy allows histological examination and staging
- Diagnosis based on cytological exam of the urine to check for presence of malignant cells and cystoscopy of the lower urinary tract
treatment of low risk TCC
- non muscle invasive
- Treated with TURBT +/- intravesical chemotherapy to bladder
treatment of high risk non muscle invasive TCC
- TURBT + intravesical chemotherapy (in bladder), intravesical BCG treatment, cystectomy
treatment of muscle invasive TCC
cystectomy (removal of bladder) and radiotherapy (with radiosensitiser) or palliative care
uncomplicated UTI causes
- Urinary tract normally sterile and resistant to bacterial colonisation
- Major defence
- Emptying of bladder during micturition
- Vesicoureteral valves
- Immunological factors
- Macrophages and neutrophils
- Mucosal barriers
- Urine acidity
MOA of UTI
- Ascending colonisation of bacteria from urethra
- Colonisation and multiplication of microorganisms
- Bladder- cystitis
- Kidney- pyelonephritis
organisms which commonly cause UTI
most common: Escherichia coli (flagellar, pili attachment, capsular polysaccharide, haemolysing and toxins)
Klebsiella pneumoniae,
RF for UTI
clinical syndromes of UTI
Cystitis (lower UTI)
- Dysuria
- Cloudy urine
- Nocturia
- Urgency
- Suprapubic tenderness
- Haematuria
- Pyrexia (usually mild)
Pyelonephritis (upper UTI)
- High fever +/- rigors
- Loin pain and tenderness
- Nausea/vomiting
- Symptoms of cystitis
other causes of dysuria
STI
post sexual intercourse
contact with irritation
vaginal atrophy
investigations for UTI
-
Urine dipstick (not usuful in pt >65)- MSU
- leucocyte esterase
- nitrites
- blood
- pH
- protein
- Urine culture if complicated UTI
- Imaging considered using US
managemnt of uncomplicated UTI
- Uncomplicated infections can be treated with nitrofurantoin, trimethoprim, pivmecillinam or Fosfomycin
- 3 days course as effective as 5 or 7
- Limiting prescription to 3 days reduces the selection pressure for resistance
management of complicated UTI
Treatment of complicated lower UTI
- E.g. male, pregnancy , catheter associated
- Nitrofurantoin, trimethoprim, pivmecillinam, Fosfomycin or cefelaxin
- Pregnant women- cefalexin
- 5-7 days
treatment of pyelonephritis/septicaemia
- 7-10 day
- Use Abx with systemic activity (not nitrofurantoin, Fosfomycin)
- Possibly IV initially unless good PO absorption and patient well enough/ tolerating orally
- Co-amoxiclav
- Ciprofloxacin (effective as a 7 day coruse)
- Gentamicin (IV only: nephrotoxic)
