Urinary Obstruction And Altered Voiding Flashcards
What are some of the causes of altered voiding?
Brain/spinal cord damage/peripheral nerve lesion
Blockage in kidneys, ureters, bladder and urethra
Prostate problems
Pelvic floor muscle problems
What are lower urinary tract symptoms (LUTS)?
LUTS involve problems with the bladder, prostate and urethra ->
Storage LUTS = incontinence, urgency, frequency, nocturia
Voiding LUTS = poor stream, hesitancy, dysuria, intermittency, double voiding (needing to go straight after going once), retention, straining, incomplete emptying
Post-micturition LUTS = terminal dribbling
What is urinary incontinence and how can it affect a patient?
Involuntary loss of urine in sufficient amount of frequency to constitute a social/health problem -> major cause of morbidity + institutionalisation, not usually life-threatening but quality of life impact (skin breakdown, pressure sores, numerous social + population issues)
What is the prevalence of urinary incontinence?
Increases with age (not normal at any age)
What are the different types of incontinence?
Stress incontinence (sphincters)
Urge incontinence (overactive bladder) - mixed (urgency and exertion problems)
Overflow incontinence
Functional incontinence
Continuous incontinence (constant leakage due to congenital, spinal cord injury, bladder fistula etc.)
Childhood incontinence/abnormal bedwetting (can indicate emotional problems)
What is stress incontinence, how is it caused, who is most likely to experience it and how can you manage i
- Pressure inside bladder becomes greater than the strength of urethra to stay closed = raised intra-pelvic pressure (e.g. pregnancy) leads to leakage due to poor sphincter resistance
- Involuntary urine leakage on effort, exertion, sneezing or coughing for e.g.
- Common in middle aged females e.g. females after child bearing with bladder neck hypermobility/poor pelvic floor muscles (rare in males except post-prostate surgery)
- Pelvic floor training, incontinence protection, duloxetine (not 1st line) + surgery
What is urge incontinence, how is it caused, who is most likely to experience it and how can you manage it?
- Involuntary urine leakage accompanied by urgency i.e. abrupt desire to void which is difficult to control = overactive bladder (detrusor muscle contracts suddenly when bladder is not full)
- Commonest cause of incontinence > 50 yrs
- Idiopathic mostly
- Consider infection, tumor, stones, bladder cancer, atrophic vaginitis, stroke, Parkinsons & dementia
- Avoid stimulants, bladder retaining, anticholinergics (oxybutynin), B3 adrenergic agonists + surgery
What is overflow incontinence, how it is caused and who is most likely to experience it?
- Prolonged problems with bladder emptying e.g. via enlarged prostate, bladder stones, constipation, spinal cord injury which lead to chronic retention and detrusor failure
- Pressure eventually rises due to tissue overdistention causing leakage
- Commonly at night and in men
What is functional incontinence, how is it caused and who is most likely to experience it?
- Consequence of something not involving LUT but involves psychological, cognitive or physical impairment
- E.G. mobility problems, dementia, diuretics (fruosemide and time to urination as works 30 minutes after taking and will probably need to wee at night if took after 4pm)
How can you investigate incontinence?
- History (quantify symptoms): precipitating events, duration, pad usage & bother (how much), medical/surgical history (parity, pelvic surgery, diabetes, CVA, other neuro disorder) + medications
- Examination: abdomen, pelvic (genitalia), digital rectum exam, neurologic exam, mental status + mobility
- Investigations: MSU, dipstick, m + c + s, cytology, FBC, U&Es, glucose, frequency-volume chart + urodynamics (cystometry)
What is involved in a frequency-volume chart?
How much you have drunk
How much urine passed
If/when there was leakage
What is a urodynamics investigation and how is it performed?
Study of pressure and flow during storage, transport and expulsion of urine in the LUT: Fill bladder (+/- contrast for imaging) -> pee -> urine flow rate -> residual urine - detrusor function measured at inflow + outflow cystometry
What is outflow cystometry and how is it performed?
Urethral catheter into bladder + transducer in rectum/vagina -> fill bladder with fluid (+/- contrast for imaging) -> record pressure in bladder + rectum/vagina -> bladder emptied and pressures recorded = bladder pressure combines abdominal + detrusor pressure whereas rectal pressure is from abdominal muscles so bladder - rectum = detrusor
What are some of the relevant neurological problems and their consequences?
Damage to brain, spinal cord and sacral region can lead to -> incontinence, retention, UTI, kidney damage (hydrostatic pressure, pyelonephritis), stones (urine stasis) + cancer (metabolite retention)
How can you manage continuous incontinence?
Usually requires surgical treatment of underlying anatomical disorder Catheterisation
How can you manage urinary retention e.g. in BPH, overflow incontinence?
Restore bladder emptying e.g. intermittent self-catheterisation, surgical treatment of bladder outflow obstruction or long-term catheter
a blockers e.g. Doxazosin
How can oxybutynin be used to treat urge incontinence/overactive bladder and what are its side effects?
- Detrusor muscle receptors include M2 + M3 and acetylcholine will stimulate these receptors to cause contraction as part of the parasympathetic pelvic nerve
- Oxybutynin is an anticholinergic that competitively inhibits M receptors, blocks acetylcholine and reduces detrusor responsiveness/activity
- Blocks M receptors throughout body so can cause dry mouth, dry eyes, constipation, heartburn, blurred vision, glaucoma, fatigue, tachycardia + urinary retention
What causes urinary obstruction?
Obstruction BPH (BPE to patient) Prostate cancer Prostatitis Haematuria causing clots (think bladder cancer if patient is ~40-45 yrs) Tumours Stones Structural (anatomy), physical or neurological
What is BPH, who is most likely to experience it and what are the symptoms?
- Enlarged prostate compresses urethra via reduced apoptosis and increased proliferation (can be normal if does not cause retention)
- Common > 50 yrs old so risks are age, changes in androgens/oestrogens, genetic factors + diabetes
- Symptoms: hesitancy, straining, weak flow, stop-start peeing, increased urgency/frequency (at night commonly), incontinence + feeling of not fully emptying the bladder
What is involved in the international prostate symptom score?
International prostate symptom score where there is 7 symptom questions: frequency, nocturia, urgency, hesitancy, poor stream, intermittency + incomplete emptying (score each one)
& 1 QOL question: If you were to spend the rest of your life with your urinary condition like this, how would you feel about that?
How do you examine/investigate BPH?
- International prostate symptom score
- PSA (sensitivity?): may identify cancer (not used as screening tool), enlarged prostate (predicts volume), prostatitis or urinary infection - can even increase if you rub prostate
- Abdominal exam
- Digital rectal exam
- Imaging e.g. transrectal US scan -> CT or MRI if cancer is suspected
How do you manage BPH and what are some of the complications of this?
- Watchful waiting whilst changing lifestyle e.g. less alcohol, caffeine, fizzy drinks, artificial sweeteners, exercise, drinking less in evening
- Drugs e.g. selective a1 blocker Doxazosin
- Surgery e.g. transurethral resection of prostate (TURP)
- Complications include UTI, acute urinary retention (emergency), incontinence + erectile problems following surgery
How can Doxazosin be used to treat urinary retention and BPH?
- Bladder neck, urethra and prostate have sympathetic neurons + a1 adrenergic receptors where noradrenaline will cause smooth muscle contraction (retention)
- Doxazosin is a selective a1 blocker so relaxes smooth muscle facilitating urinary flow - flow proportional to vessel diameter (small increase in diameter = large increase in flow)
- Side effects as a1 blocked throughout body: nausea, dry mouth, fatigue, constipation but also anxiety, back pain, coughing, dyspnoea, fatigue, influenza-like symptoms, myalgia, paraesthesia, sleep disturbance and vertigo (BNF)
What should a normal and abnormal prostate feel like? How can you differentiate between BPH and cancer?
Healthy: soft, smooth, symmetrical, regular + even
Abnormal: hard, lumpy + irregular
Peripheral zone: largest area, felt during rectal exam, most cancers start here so PZ will enlarge
Transition zone: surrounds urethra, increases with age and BPH
BPH causes symptoms but cancer has few although can be felt on prostate DRE
