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60yo man. CC: weak stream, hesitancy, incomplete emptying/straining…
60yo man. CC: weak stream, hesitancy, incomplete emptying/straining
Chronic LUTS - voiding symptom dominant
~progressive voiding symptoms (hesitancy, slow stream, intermittancy, straining to void, terminal dribble)
Benign prostatic hyperplasia
~storage+voiding+irritative symptoms gradual onset (yrs)
~rectal exam - smooth enlarged non-tender prostate with palpable median sulcus & mobile rectal mucosa over prostate
~Uroflowmetry - volume voided >150ml, peak flow rate < 15ml/s
Urethral stricutre
~PHx urinary instrumentation/STDs
~recurrent UTI, urinary spraying, dysuria
~poor bladder emptying with low peak rate of urine flow
Penile causes
~edema & tenderness of glans penis
~painful swelling of distal retracted foreskin
~constricting band of tissue proximal to head of penis
~penile shaft appears flaccid & unaffected
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Neurogenic bladder
~PHx: neurological disease, lax anal tone, abnl LL neurological examination
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Prostate/bladder neck cancer
~painless hematuria, loss of weight, suspicious rectal exam (hard, irregularly nodular prostate with loss of median sulves& non-mobile overlying rectal mucosa)
Complications:
~acute on chronic urinary retention - presents as retention alone/overflow incontinence
~Recurrent infection - e.g. cystitis, pyelonephritis, pyonephrosis to which obstruction prediposes
~obstructive uropathy - back pressure causing hydronephrosis & post-renal AKI/CKD. Do serum Cr, electrolytes, ultrasound kidney esp if there is high post-void residual vol
~bladder stone formation
~effects of chronic straining - hernia
Bladder diverticulum
~usually asymptomatic, but classically have postvoid dribbling, dysuria, dyspareunia
~typically between 20-60yo
Acute urinary retention
~usually highly distressed elderly man with palpable suprapubic mass
~large urine o/p upon catheterization
Obstructive (usually in pt w known urologic dz)
~urinary tract obstruction - usually BPH, but also urethral stricture, urethral stone, phimosis, praphimosis
~constipation - fecal impaction, common precipitating factor
~catheter blockage - clots 2 hematuria
Infective (fever, hematuria, dysuria)
~UTI
~acute prostatitis - obstructive & irritative symptoms (signs of systemic sepsis & perineal/back pain
Neurologic - w back pain, weakness, trauma
~cauda equina syn & cord compression (back pain, sciatica, trauma or known metastatic cancer)
~central neurology - stroke, parkinsons, multiple system atrophy
~Peripheral neurology - neurogenic bladder
Drugs
~anticholinergic SE (antihistamines, antipsychotics, tricyclic antidepressants, hyoscine)
~opoids, alpha agonist (pseudoephedrine)
Acute urinary infection
~acute onset of dysuria, storage symptoms (urgency, freguency), a/w pyuria (cloudy/foul-smelling urine) +/- hematuria +/- suprapubic pain
UTI
~lower (cystitis) - pt is generally well (mild fever)
~upper (pyelonephritis) - sepsis (fever, hypotension), flank pain, +ve renal punch
Prostatitis
~febrile & ill pt w perineal pain/backache & irritative urinary symptoms (dysuria, frequency, urgency)
~pain on ejaculation & a tender, broggy prostate +/- suprapubic tenderness
~usually gram -ve rods/STDs
Urethritis
~dysuria + non-bloody urethral discharge
~sign of STDs (gonorrhoea, chlamydia) - look for discharge around genitals & STD lesions (ulcers, vesicles, crusting)
Epididymo-orchitis
~a/w STD but signs of acute testis (tender testis, epididymitis, spermatic cords)