Urinary Tract Obstruction

Question 1

When may a unilateral urinary tract obstruction be clinically silent?

Answer 1

If the other kidney is functioning normally

Question 2

What are some examples of when a urinary tract obstruction requires urgent treatment?

Answer 2

If the obstruction is bilateral, or there is obstruction with infection

Question 3

How does an acute upper urinary tract obstruction typically present?

Answer 3

Loin to groin pain

Question 4

Symptoms of loin pain, renal failure, superimposed infection and polyuria suggest what type of urinary tract obstruction?

Answer 4

Chronic upper urinary tract obstruction

Question 5

Why does chronic upper urinary tract obstruction cause polyuria?

Answer 5

There is a reduced concentrating ability of the kidney

Question 6

How does an acute lower urinary tract obstruction typically present?

Answer 6

Acute urinary retention

Question 7

Overflow incontinence can be a feature of which type of urinary tract obstruction?

Answer 7

Chronic lower urinary tract obstruction

Question 8

If a patient presents with any signs/symptoms of urinary tract obstruction, what two bedside tests must always be done?

Answer 8

Bloods for U&Es, urine for MC&S

Question 9

What is the first line imaging modality of choice for someone with a suspected urinary tract obstruction?

Answer 9

Ultrasound

Question 10

When should a CT scan be arranged for someone with urinary tract obstruction?

Answer 10

If there is hydronephrosis or hydroureter on ultrasound scans

Question 11

What are the two main treatment options for an upper urinary tract obstruction?

Answer 11

Nephrostomy or ureteric stent

Question 12

What medication can be used to help reduce the pain associated with a ureteric stent?

Answer 12

Alpha blockers

Question 13

How is a lower urinary tract obstruction treated?

Answer 13

Insert a catheter and treat the underlying cause if possible

Question 14

What are the two main causes of urinary retention?

Answer 14

Obstruction, or reduced detrusor muscle power

Question 15

What are the two main causes of acute urinary retention?

Answer 15

Prostatic enlargement and urethral strictures

Question 16

What group of medications are a recognised cause of acute urinary retention?

Answer 16

Anti-cholinergic medications

Question 17

If a patient is in acute urinary retention and fails to void, how should they be treated?

Answer 17

Catheterisation and an alpha blocker (e.g. tamsulosin)

Question 18

How are patients who are in acute urinary retention as a result of clot retention treated?

Answer 18

3-way catheter and bladder washout

Question 19

Why should patient’s U&Es always be monitored closely after catheterisation for acute urinary retention?

Answer 19

Risk of post-obstructive diuresis and salt-losing nephropathy

Question 20

Why may chronic urinary retention lead to renal failure?

Answer 20

Bilateral obstructive nephropathy

Question 21

Treating the underlying cause is the best way to manage chronic urinary retention. What else can be used to help control the condition, regardless of the underlying cause?

Answer 21

Intermittent self catheterisation

Question 22

In patients with chronic urinary retention, an episode of acute urinary retention may only be recognised when what symptom develops?

Answer 22

Overflow incontinence

Question 23

After placing a catheter in someone with acute-on-chronic urinary retention, what may happen with regards to their renal function?

Answer 23

There may be a significant rise in creatinine, but this usually returns to baseline after a few days

Question 24

If you suspect obstructive uropathy, what imaging investigation should always be requested?

Answer 24

Renal ultrasound

Question 25

What can be done to try and avoid post-obstructive diuresis in patients who have been catheterised as a result of urinary retention?

Answer 25

Give resuscitation fluids, and then match input with output

Question 26

What can be done to try and avoid salt-losing nephropathy in patients who have been catheterised as a result of urinary retention?

Answer 26

Give isotonic (1.26%) sodium bicarbonate solution and withhold any nephrotoxic drugs

Question 27

What type of disorder is idiopathic retroperitoneal fibrosis?

Answer 27

Autoimmune

Question 28

What type of urinary tract obstruction is caused by retroperitoneal fibrosis?

Answer 28

Progressive, bilateral urinary tract obstruction

Question 29

What type of malignancy is a recognised secondary cause of retroperitoneal fibrosis?

Answer 29

Lymphoma

Question 30

Who does retroperitoneal fibrosis typically present in?

Answer 30

Middle aged males

Question 31

How does retroperitoneal fibrosis typically present?

Answer 31

Vague loin/back/abdominal pain and hypertension

Question 32

What is the first line imaging test for retroperitoneal fibrosis and what would it show?

Answer 32

Ultrasound- would show dilated ureters and hydronephrosis

Question 33

If an US scan is suggestive of retroperitoneal fibrosis, what is the next best investigation to do and what would it show?

Answer 33

CT or MRI- would show a peri-aortic mass

Question 34

How is retroperitoneal fibrosis treated?

Answer 34

Bilateral retrograde stenting

Question 35

Other than prostatic enlargement, what is another commonly recognised cause of bladder outflow obstruction?

Answer 35

Urethral strictures

Question 36

How is a urethral stricture causing bladder outflow obstruction usually managed?

Answer 36

Dilatation

Question 37

BPH causes hyperplasia of which cells of the prostate?

Answer 37

Both stromal and epithelial cells

Question 38

Which zone of the prostate is typically affected by BPH?

Answer 38

Transitional zone

Question 39

Is BPH a pre-malignant disease?

Answer 39

No

Question 40

What investigation can be used to identify incomplete emptying in those with suspected BPH?

Answer 40

Uroflowmetry

Question 41

What should always be done before a PR exam in someone presenting with suspected prostatic enlargment?

Answer 41

Bloods for PSA

Question 42

What investigations are done to exclude a malignancy in someone presenting with suspected BPH?

Answer 42

PSA bloods, TRUS +/- biopsy

Question 43

What is the first line group of drugs for the management of BPH- give an example?

Answer 43

Alpha blockers e.g. tamsulosin

Question 44

What is the second line group of drugs for the management of BPH- give an example?

Answer 44

5 alpha reductase inhibitors e.g. finasteride

Question 45

How does tamsulosin work in the treatment of BPH?

Answer 45

Decreases smooth muscle tone of the bladder and prostate

Question 46

How does finasteride work in the treatment of BPH?

Answer 46

Reduces dihydrotestosterone levels (and hence the size of the prostate)

Question 47

Finasteride can take up to how long to be effective in the treatment of BPH?

Answer 47

6 months

Question 48

What are some side effects of finasteride?

Answer 48

Impotence and decreased libido

Question 49

What is the surgical treatment of choice for bladder outflow obstruction caused by BPH?

Answer 49

Trans-urethral resection of the prostate (TURP)

Question 50

What happens in the complication of a TURP procedure known as trans-urethral resection syndrome?

Answer 50

Acute hyponatraemia

Question 51

What is a transient complication that sometimes occurs after a TURP procedure but rarely becomes a persistent problem?

Answer 51

Incontinence

Question 52

What are some potential complications of a TURP procedure, to do with sexual function?

Answer 52

Impotence and retrograde ejaculation

Question 53

For how long after a TURP procedure should patients avoid driving and sexual activity?

Answer 53

2 weeks

Question 54

What complication may be expected in the first 2 weeks following a TURP procedure, and patients should be warned not to worry about?

Answer 54

Haematuria

Question 55

Initially following a TURP procedure, patients may need to urinate more frequently than usual. How long will it take for the procedure to work and this complication to stop?

Answer 55

6 weeks