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GP block (Y3) > Week 6: Womens' health (3) (urinary symptoms) > Flashcards

Week 6: Womens' health (3) (urinary symptoms) Flashcards

1
Q

urinary frequency

A

high frequency with normal 24-hour volume

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2
Q

polyuria

A

passing more urine than usual (up to 3l of urine in 24horus is normal)

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3
Q

nocturia

A

waking at night to urinate

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4
Q

hesitancy

A

difficult urinating i.e. starting stream or keeping it going

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5
Q

anuria

A

no urination

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6
Q

Lower urinary tract symptoms (LUTS) cna be split into

A

storage symptoms

voiding symptoms

post-micturition symptoms

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7
Q

storage symptoms

A
  • Polyuria
  • Nocturia
  • Urgency
  • Incontinence
    • Stress
    • Urge
    • Mixed
    • Enuresis
    • Bladder sensation (normal, increased, reduced, absence, non-specific)
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8
Q

voiding symptoms

A
  • Slow stream
  • Spraying
  • Hesitancy
  • Terminal dribble
  • Straining to void
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9
Q

post micturition

A
  • Feeling of incomplete emptying
  • Post micturition dribble
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10
Q

causes of LUTS in women

A
  • UTI
  • UI
  • anxiety
  • Overactive bladder
  • bladder tumour or stone
  • prolapse
  • urinary tract stone
  • neurological disease
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11
Q

RF for LUTS in women

A
  • Age
  • Being overweight
  • Number of children
  • Abnormalities of urogenital system
    • Pelvic organ prolapse
    • Female genital tract abnormality
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12
Q

presentation of lUTS in women

A
  • 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
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13
Q

investigations for LUTS in women

A
  • urine: urinalysis, MSU, pregnancy test, haematuria, infection
  • renal function and electrolytes, FBG
  • frequency chart, bladder diary, genitourinary swaps
  • intravenous pyelogram
  • US
  • urodynamic studies
  • cystoscopy
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14
Q

general management of LUTS in women: UTI

A

non-pharmacological

  • bladder emptying after sex

pharmacological

  • antibiotics
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15
Q

general management of LUTS in women: Urinary incontinence / oAB

A

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
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16
Q

general management of LUTS in women: prolapse

A
  • ring pessaries may be useful where surgery for prolapse not possible
  • reduce weight if >30kg/m2
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17
Q

general management of LUTS in women: nocturnal enuresis or diabetes insipidus

A
  • desmopressin
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18
Q

LUTS in men

A
  • 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
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19
Q

causes of LUTS in men

A
  • BPH with obstruction
  • detrusor muscle weakness
  • UTI
  • urinary tract stones
  • malignancy : prostate or bladder cancer
  • neurological disease e.g. MS
  • polyuria secondary to DM
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20
Q

RF for LUTS

A
  • increase serum dihydrotesterone levels
  • obesity
  • elevated fasting glucose/diabetes
  • inflammation
  • NSAIDs decrease risk
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21
Q

presentation of LUTS in men: storage

A
  • urinary frequency, urgency, dysuria, nocturia
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22
Q

presentation of LUTS in men: voiding

A
  • : poor stream, hesitancy, terminal dribble, incomplete voiding, overflow incontinence
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23
Q

general red flags for LUTS presentation

A
  • haematuria, fever, loin and pelvic pain- UT
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24
Q

signs of LUTS in men

A
  • palpable bladder
  • rectal exam (prostate: size, tenderness, nodules)
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25
Q

investigations for LUTS in men

A
  • history to identify possible causes and comorbidities
  • exam of abdomen
  • urine dipstick
  • urinary frequency volume chart
  • renal function test
  • DRE
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26
Q

general management of LUTS in men: storage symptoms

A

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
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27
Q

general lifestyle management for LUTS

A
  • reduce fluid intake (but not too much) containing alcohol, caffeine and artificial sweetners
  • distraction techniques such as breathing exercises
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28
Q

general management of LUTS in men: voiding symptoms

A

conservative

  • intermittent bladder catherization
  • bladder training less effective than surgery

pharmacological

  • BPH- alpha blocker e.g. tamsulosin
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29
Q

general management of LUTS in men: acute vs chronic retention

A
  • acute retention
    • catheterise
    • offer alpha blocker before removing catheter
  • chronic retention
    • catheterise
    • surgery if symptoms are bad
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30
Q

urinary incontinence

A

Complaint of any involuntary leakage of urine… associated with…

  • Massive impact on QoL
  • Social exclusion
  • Sense of shame
  • Just put up with it attitude
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31
Q

types of incontinence SUMO

A

stress

Urge

mixed

overflow

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32
Q

stress incontinence

A
  • 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
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33
Q

urge incontinence

A
  • 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
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34
Q

mixed urinary incontinence

A
  • The complaint of involuntary leakage (or urine) associated with urgency and also with exertion, effort, sneezing or coughing
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35
Q

overflow incontinence

A
  • Caused by an obstruction or blockage in bladder à prevents from fully emptying
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36
Q

Functional incontinences

A

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).

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37
Q

management of urge incontinence

A
  • 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)
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38
Q

management of stress incontinence

A
  • 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
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39
Q

acute urinary retention

A
  • sudden inability to pass urine
  • usually painful and requires emergency treatment with a catheter
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40
Q

causes of acute urinary retention in men

A

BPH, meatal stenosis, paraphimosis, penile constricting bands, phimosis, prostate cancer, balanitis, prostatitis, prostatic abscess

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41
Q

causes of acute urinary retention in women

A

prolapse (cystocele, rectocele, uterine), pelvic mass (gynaecological malignancy, uterine fibroids, ovarian cyst)

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42
Q

causes of acute urinary retention in both

A
  • bladder calculi, bladder cancer, faecal impaction, GI malignancy, urethral stricture, foreign bodies, UTI
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43
Q

drugs which cause urinary retention

A

anticholinergics, opioids, anaesthetics, alpha-adrenoreceptor agonists, benzos, NSAIDs, alcohol, CCB

44
Q

neurological causes of urinary retention

A
  • peripheral nerve e.g. DM, Guillain-Barre syndrome, pernicious anaemia
  • brain: stroke, MS, Parkinson’s
  • spinal cord: invertebral disc. disease, meningomyelocele, MS, cauda equina)
45
Q

presentation of acute urinary retention

A
  • unable to pass urine
  • extreme discomfort
  • tender, distended bladder
46
Q

Investigations of acute urinary retention

A
  • 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
47
Q

management of acute urinary retention

A
  • 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
48
Q

chronic urinary retention

A
  • 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
49
Q

chronic urinary retention causes

A
  • 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
50
Q

presentation of chronic urinary retention

A
  • 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
51
Q

investigations of chronic urinary retention

A
  • urinalysis
  • MSU for microscopy
  • blood tests (U&Es, FBC, blood glucose, PSA)
  • voiding diary
  • imaging
52
Q

management of of chronic urinary retention

A
  • 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
53
Q

Post obstructive diuresis

A
  • 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
54
Q

Hydronephrosis

A

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:

  1. Unilateral- caused by upper urinary tract obstruction
  2. Bilateral- caused by obstruction in the lower tract
55
Q

hydronephrosis results in

A
  1. Progressive atrophy of kidney develops as the back pressure from the obstruction transmitted to the distal part of the nephron
  2. GFR declines, if bilateral= renal failure
56
Q

diagnosis of upper urinary tract obstruction

A
  • 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
57
Q

Diuretic renography (MAG3) = functional test

A
  • 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
58
Q

enuresis in children

A
  • 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?
59
Q

management of enuresis in patients without daytime symptoms

A
  • Usually managed in primary care
  • Reassurance, alarms with positive reward system, ?desmopressin (man made vasopressin)
60
Q

management of enuresis in pt with daytime symptoms

A
  • Usually caused by disorders of the lower urinary tract e.g. anatomical, OAB
  • NICE recommends referral to secondary care
61
Q

management of secondary enuresis

A
  • Treat underlying cause if it has been identified e.g. UTIs, constipation, diabetes, psychological problems, family problems, physical or neurological problems
  • Primary/secondary care
62
Q

flow volume chart

A

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).
63
Q

benign prostatic hyperplasia

A
  • 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
64
Q

presentation of BPH

A
  • urinary frequency
  • urinary urgency
  • hesitancy
  • incomplete bladder emptying
  • push or strain
  • UTI
  • urinary retention
65
Q

investigation of BPH

A
  • 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
66
Q

management of BPH

A
  • 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)
67
Q

Carcinoma of the prostate

A
  1. Commonest cancer in men
  2. 2nd commonest cause of death from cancer in men
  3. 1 in 8 men will be diagnosed with prostate cancer
  4. Rare in men <59
68
Q

RF for prostate cancer

A
  1. Increased age
  2. Family history (BRACA2 gene mutation)
  3. Ethnicity
    1. Black > White >Asian
69
Q

zones of the prostate

A
70
Q

Lesions most commonly found in the periphery of the posterior part of the prostate

A

prostate cancer

71
Q

BPH hypertrophy occurs

A

in the central location

72
Q

presentation of prostate cancer

A
  • 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
73
Q

PSA and prostate cancer

A
  • Increasingly found following investigation of elevated prostate- specific antigen (PSA) in otherwise asymptomatic man
  • Prostate specific antigen (PSA)
74
Q

causes of raised PSA

A
  • Prostate cancer
  • Infection
  • Inflammation
  • Large prostate
  • Urinary retention
75
Q

classification of prostate cancer

A

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
76
Q

diagnosis of prostate cancer

A
  • 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
77
Q

treatment of localise dprostate cancer

A
  • 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
78
Q

treatment of advanced prostate cancer

A
  • 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
  • Palliative care
79
Q

prognosis of prostate cancer

A
  • 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
80
Q

types of renal cancer

A

renal cell carcinoma transitional cell carcinoma

81
Q

renal cell carcinoma

A

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
82
Q

RF of RCC

A
  • Male: female ratio 3:1
  • Risk factors
    • Dialysis
    • Smoking
    • Obesity
83
Q

presentation of RCC

A
  • 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
84
Q

investigations for RCC

A
  • Radiology- US or CT
  • Endoscopy- flexible cystoscopy
  • Urine- cytology
85
Q

treatment of RCC: localised

A
  • 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
86
Q

treatment of metastatic RCC

A
  • Little effective treatment for metastatic disease
  • Chemotherapy and radiotherapy resistant
  • Palliative treatment- target angiogenesis
87
Q

transitional cell carcinoma

A
  • Can affect anywhere from the calyx to the bladder
    • Most commonly found in bladder
88
Q

presentation of TCC

A
  • Haematuria
  • Incidental finding on imaging (US or CT)
  • Weight loss
  • Loss of appetite
  • Signs/symptoms of obstruction
89
Q

RF of TCC

A
  • 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)
90
Q

staging of TCC

A
  • 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
91
Q

diagnosis of TCC

A
  • 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
92
Q

treatment of low risk TCC

A
  • non muscle invasive
    • Treated with TURBT +/- intravesical chemotherapy to bladder
93
Q

treatment of high risk non muscle invasive TCC

A
  • TURBT + intravesical chemotherapy (in bladder), intravesical BCG treatment, cystectomy
94
Q

treatment of muscle invasive TCC

A

cystectomy (removal of bladder) and radiotherapy (with radiosensitiser) or palliative care

95
Q

uncomplicated UTI causes

A
  • 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
96
Q

MOA of UTI

A
  • Ascending colonisation of bacteria from urethra
  • Colonisation and multiplication of microorganisms
    • Bladder- cystitis
    • Kidney- pyelonephritis
97
Q

organisms which commonly cause UTI

A

most common: Escherichia coli (flagellar, pili attachment, capsular polysaccharide, haemolysing and toxins)

Klebsiella pneumoniae,

98
Q

RF for UTI

A
99
Q

clinical syndromes of UTI

A
100
Q

Cystitis (lower UTI)

A
  • Dysuria
  • Cloudy urine
  • Nocturia
  • Urgency
  • Suprapubic tenderness
  • Haematuria
  • Pyrexia (usually mild)
101
Q

Pyelonephritis (upper UTI)

A
  • High fever +/- rigors
  • Loin pain and tenderness
  • Nausea/vomiting
  • Symptoms of cystitis
102
Q

other causes of dysuria

A

STI

post sexual intercourse

contact with irritation

vaginal atrophy

103
Q

investigations for UTI

A
  • Urine dipstick (not usuful in pt >65)- MSU
    • leucocyte esterase
    • nitrites
    • blood
    • pH
    • protein
  • Urine culture if complicated UTI
  • Imaging considered using US
104
Q

managemnt of uncomplicated UTI

A
  • 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
105
Q

management of complicated UTI

A

Treatment of complicated lower UTI

  • E.g. male, pregnancy , catheter associated
  • Nitrofurantoin, trimethoprim, pivmecillinam, Fosfomycin or cefelaxin
  • Pregnant women- cefalexin
  • 5-7 days
106
Q

treatment of pyelonephritis/septicaemia

A
  • 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)

GP block (Y3) (39 decks)

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