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SURGERY - Urology > LUTS in men and women > Flashcards

LUTS in men and women Flashcards

1
Q

Common storage symptoms in men with LUTS

A

Frequency
Nocturia
Urgency
Urge incontinence

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2
Q

Common voiding symptoms in men with LUTS

A

Hesitancy
Poor flow
Straining
Intermittancy

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3
Q

Common post-micturition urinary symptoms in men with LUTS

A

Sensation of incomplete emptying

Post micturition dribble

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4
Q

Common causes of male LUTS

A

Bladder outflow obstruction
(usually due to BPH or urethral strictures)

Overactive bladder
(can be primary or secondary to obstruction/carcinoma in-situ/neuro/radiation/infection)

Urinary tract infection
(prevent with dysuria, positive dip)

Bladder stones

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5
Q

symptoms that characterise bladder outflow obstruction (BOO)

A 
Hesitancy
Poor flow
Intermittent flow
Post-micturition dribble
Incomplete emptying
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6
Q

symptoms that characterise overactive bladder syndrome (OAB)

A
  • in men it accompanies obstruction
  • URGENCY with/without incontinence
  • often accompanied by frequency and nocturia
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7
Q

describe flow-rate testing (uroflowmetry)

A
  • You need a voided vol of 150mls minimum

If Qmax>15mls/sec = 10-30% chance of obstruction
If Qmax 10-15mls/sec = 60% chance of obstruction
If Qmax <10mls/sec = 90% chance of obstruction

Filling:

  • should be slow gentle rise in pressure
  • phasic contractions = detrusor overactivity and urgency (feature of OAB)
  • patient asked to cough to look for stress incontinence

Voiding:

  • high pressure + low flow = obstruction
  • low pressure + low flow = detrusor failure
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8
Q

What are the medical (drug) treatments for BOO

A

Medical =

alpha blockers
(tamsulosin, alfuzosin)
- relax prostatic/bladder neck smooth muscle
- SEs = only symptomatic control, retrograde ejaculation, postural hypotension

5-alpha reductase inhibitors (finasteride/ dutasteride)

  • reduce conversion of testosterone to DHT, reduces prostatic volume
  • only works when BPH is the problem (PSA>1.4, prostate>30g)
  • reduces progression of disease
  • SEs = erectile dysfunction, decreased libido, rash

anticholinergics (if OAB symptoms too)

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9
Q

What are the conservative and surgical treatments for BOO.

When is surgery indicated?

A

Conservative = advise on fluid intake, caffeine, etc

Surgical =

  • TURP or laser prostate surgery
  • Open retropubic (Millin’s) prostatectomy
  • Needed in failure of medical therapy or development of complications eg. chronic retention, bladder stones, persistent haematuria
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10
Q

Investigations you would do for LUTS

A
  • History
  • Post-void bladder scanning and flow rate
  • Urinary freq and vol chart
  • Urinalysis (haematuria in bladder stones, glycosuria in DM, etc)
  • Urine culture to investigate infection
  • Routine bloods (FBC, U&Es)
  • Urodynamic studies
  • Cystoscopy to investigate lower urinary tract
  • US or CT scanning for upper urinary tract imaging to investigate retention etc.
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11
Q

Risks of TURP?

A

TURP syndrome

  • hypoosmolar irrigation for standard TURP is glycine (as it acts as electrical insulator)
  • absorption through exposed venous beds during a long resection can lead to dilutional hyponatraemia = fits, confusion, visual symptoms, coma

Avoid this with bipolar TURP and laser TURP

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12
Q

How do you you distinguish between Overactive Bladder/Urge-Incontinence from Stress incontinence

A

Stress

  • provoked by coughing/sneezing/laughing/standing
  • leaks a SMALL amount
  • no sensation of urge

Urge

  • preceded by sensation of urgency
  • can also be provoked by coughing
  • also provoked by running water, cold, “latch-key”
  • leak LARGE amounts
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13
Q

What are the common causes of incontinence in women?

A
  • pregnancy or vaginal delivery
    (stretching and weakening of muscles + damage to pudendal and pelvic nerves)
  • overweight
  • old age
  • constipation
  • dementia
  • strenuous activities eg. weight lifting
    (increased stress on pelvic support structures)
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14
Q

What are the conservative and surgical treatment options for stress incontinence

A

Conservative

  • weight loss
  • pelvic floor exercises
Surgical
- examine for prolapse and treat if present 
- Tension-Free Vaginal Tape and Transobturator Tape are the gold standard
(risk of erosion)
- Autologous slings
- Colposuspension
- Artificial sphincter mostly in men
- Urinary diversion
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15
Q

Which neuro conditions can commonly impact on bladder/sphincter function?

A

Spina bifida

  • causes neurogenic OAB and stress incont
  • risk of hydronephrosis/ renal failure

Spinal Cord Injury

  • causes neurogenic OAB or areflexic bladder
  • can cause overactive sphincter (Detrusor-sphincter dyssynergia) or underactive sphincter (Neurogenic Stress Incontinence)

Diabetes, MS, Parkinsons all have low risk of renal failure

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16
Q

Common causes of stress incontinence in men?

A
  • surgical injury to external sphincter or its nerve supply (radical prostatectomy or TURP)
  • Neuro problem affecting sphincter
  • treat with artificial sphincter or male sling

*** with artificial sphincter, make sure to deactivate before catheterisation!!!

17
Q

What is BPH?

A

non-cancerous hyperplasia of the glandular-epithelial and stromal tissue of the prostate leading to an increase in its size.

Most common cause of Bladder Outlet Obstruction in men.

18
Q

Risk factors for developing BPH

A

Family history

Old age

Afro caribbean ethnicity

Obesity

19
Q

How do patients with BPH present?

A

LUTS

voiding symptoms (hesitancy, weak stream, terminal dribbling, incomplete emptying)

storage symptoms (urinary freq, nocturia, nocturnal enuresis, urge incontinence)

Haematuria (uncommon)

Haematospermia (uncommon)

20
Q

How do you distinguish between BPH and prostate cancer?

A

DRE

firm, smooth, symmetrical prostate is low risk of cancer.

21
Q

How would you manage BPH if there were no significant complications?

A

Every patient completes an International Prostate Symptom Score (IPSS) questionnaire

if there are no significant complications, simply reassurance and advice is enough eg. moderate caffeine and alcohol

22
Q

How would you investigate BPH? (usually present with LUTS)

A

Urinary freq and volume chart

Bedside urinalysis to exclude UTI

post-void bladder scan to assess significant chronic retention

Prostate Specific Antigen
(still elevated in BPH even without malignancy so not that accurate)

Ultrasound of renal tract to check for hydronephrosis, etc

Urodynamic studies

23
Q

Medical management for BPH?

A

a-adrenoreceptor antagonist (a-blockers)
Eg. tamsulosin
= relax prostatic smooth muscle (symptomatic benefit)

5a-reductase inhibitors if a-blockers don’t work
Eg. Finasteride
= prevent conversion of testosterone to DHT, causing decrease in prostatic vol

24
Q

Surgical management of BPH

A

TransUrethral Resection of the Prostate (TURP)
= removal of obstructive prostate tissue

SE = haemorrhage, sexual dysfunction, retrograde ejaculation, urethral stricture

SURGERY - Urology (6 decks)

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